Mississauga
3427 Derry Rd East, Suite #201,
Mississauga, ON L4T 4H7
testing@tastechnologies.com
905-672-2244
CHAGGER DENTAL PATIENT INFORMATION
Submitted: 2026-05-18 10:03 AM
PATIENT PROFILE
Title
Mr.
Ms.
Mrs.
Full Name
John Doe
Age
22
Sex
Male
Female
Others
 
Marital Status
Single
Married
Prefer Not to Say
Date of Birth
2026-05-01
Street Address
1155 North Service Rd W Suite 11
City
Oakville ON
Province / State
Oakville
Postal Code
L6M 3E3
 
Email Address
vikash@tastechnologies.com
Home Phone
416-578-0907
Cell Phone
416-578-0907
Occupation
NA
Employed By
NA
DENTAL INSURANCE & CARE PROVIDERS
Dental Insurance?
Yes
No
Company
NA
Policy No.
NA
ID / Cert No.
NA
Family Physician
NA
Physician Phone
NA
Previous Dentist
NA
Previous Dentist Phone
NA
Referral Credit
NA
EMERGENCY CONTACT
Contact Name
NA
Relationship
NA
Address
NA
Phone Number
NA
CONFIDENTIAL MEDICAL HISTORY
1. Date of last complete physical examination 2026-05-02
2. Are you currently under a physician's care?
Yes
No
Specify
NA
3. Do you have frequent headaches?
Yes
No
4. Do you smoke?
Yes
No
5. Do you drink alcohol?
Yes
No
Specify
NA
6. Do you do recreational drugs?
Yes
No
7. Do you routinely take vitamins, herbal substances, or natural products?
Yes
No
Specify
NA
8. Are you taking any medications?
Yes
No
Specify
NA
9. Have you taken any prolonged medication in the past?
Yes
No
Specify
NA
10. Have you taken cortisone or steroids?
Yes
No
11. Have you ever been hospitalized for any surgery?
Yes
No
Specify
NA
12. Are your ankles often swollen?
Yes
No
13. Have you gained or lost excessive weight recently?
Yes
No
14. Are you pregnant?
Yes
No
Specify
15. Sensitive / adverse reactions
✔ Latex
Penicillin
✔ Metals
✔ Sulfa Drugs
   
16. Allergies / adverse reactions
✔ Aspirin
✔ Local Anesthetic (Freezing)
✔ Barbiturates (Sleeping pills)
✔ Nitrous Oxide
Codeine
 
17. Allergic or adverse reactions to any other drugs?
Yes
No
Specify
NA
18. Treated for or told you have any of the following
✔ COVID-19
Heart Murmur
✔ Arthritis
Hepatitis B
✔ Asthma
HIV (AIDS)
✔ Blood Disorder
Hypertension / Low BP
✔ Anemia
Liver Disease
Leukemia
Mental Disability
✔ Cardiovascular Disease
✔ Renal Disease
✔ Cancer
Rheumatic Fever
Diabetes Type I / Type II
Thyroid Disease
Emphysema
✔ Tuberculosis
✔ Epilepsy
✔ Venereal Disease
   
19. Have you ever experienced heavy bleeding?
Yes
No
20. Is there anything else we should know?
Yes
No
Specify
NA
21. Have you been diagnosed with any other disease, condition or problem?
Yes
No
22. Is there anything about your health we should be aware of?
Yes
No
Specify
NA
23. Do you wish to speak to the doctor privately?
Yes
No
CONFIDENTIAL DENTAL HISTORY
24. Date of last complete exam 2026-05-07
25. Date of last cleaning 2026-05-08
26. Date of last x-rays 2026-05-09
27. Did you see your last dentist regularly?
Yes
No
28. How often did you see your last dentist? 3 Months
Specify
NA
29. Have you ever been advised to take antibiotics?
Yes
No
30. Heavy bleeding following extractions?
Yes
No
31. Have you ever had gum treatment or surgery?
Yes
No
32. Have you had any orthodontic treatment?
Yes
No
33. Have you ever had an unpleasant dental experience?
Yes
No
34. How can we make your dental experience more pleasant? NA
35. Is there anything else we should know? NA
36. What brings you to the office today? NA
37. Are you in any discomfort?
Yes
No
Specify
NA
38. Do you have or have you experienced
✔ Tooth sensitivity
✔ Bad breath
Ear ache
✔ Headaches
✔ Bleeding gums
Sore gums
✔ Gagging
Missing teeth
✔ Loose Teeth
Spaced or Crooked teeth
Unexplained nosebleed
Unsatisfactory dentures
Difficulty opening or closing
✔ Lump or swelling in your mouth
✔ Clench or Grind
Neck pain
Popping or clicking in the jaw joints
Thyroid Disease
✔ Emphysema
✔ Tuberculosis
✔ Epilepsy
✔ Venereal Disease
   
39. Does food get caught between your teeth?
Yes
No
40. Do you have any sore spots in your mouth?
Yes
No
41. Have you had any teeth replaced?
Yes
No
42. Interested in permanent tooth replacement?
Yes
No
43. Have you ever been given local anesthesia?
Yes
No
44. Have you ever been given general anesthesia?
Yes
No
45. Are you satisfied with the appearance of your teeth?
Yes
No
46. Are you anxious to keep your natural teeth?
Yes
No
47. Are you tense during dental visits?
Yes
No
48. Interested in a method to calm your nerves?
Yes
No
49. How can we help you today?
Just for testing purpose, please ignore it.
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SIGNATURE


PRINT NAME
John Doe

© 2026 Chagger Dental • Confidential Medical Record