Are you the: (Required)
PATIENTPARENTGUARDIAN
Salutation (Required)
---Mr.Mrs.Ms.Dr.Prof.
Last Name (Required)
First Name (Required)
Initial
Address (Required)
Street Address
City
State
ZIP Code
Date of Birth (Required)
Age
Sex
---MaleFemaleOther
Marital Status
---SingleMarriedDivorcedWidowedOther
Home Phone (Required)
Driver's Lic. No. (Required)
Employer (Required)
Phone (Required)
Ext.
Referring Dr.
Phone
Family Physician
Address
Medical Specialist
Last Name
First Name
Prefers to be called
Date of Birth
School
Grade
Person Responsible for account:
SelfSpouseOther
Method of payment:
CashChequeCredit Card
If other, please complete the following:
Name
Home Phone
Employer
Spouse's Name
Occupation
In case of emergency
Closest family relative
Is another family member or relative a patient at our office?
YesNo
Name of Insured
Date
Insurance Carrier
Group/Policy Number
Division
I.D. Number or S.I.N.
Certificate Number
Dept. No.
Coverage Percentage
A
B
C
D
Limits
Basic
Major
Ortho
Deductible
Per Person
Per Family
Signature(s) Required
PatientInsuredEmployer
Submission
CareerPatientEmployerOther
The information is required by the dentist to assist in proper diagnosis and treatment. ALL INFORMATION IS CONFIDENTIAL
1. Have you ever had a serious illness requiring hospitalization or extensive medial care?
YesDon't Know/MaybeNoOther
Other
2. Are you presently under the care of a physician?
YesDon't Know/MaybeNo
If so, explain
3. Have you been hospitalized in the last 5 years?
4. Have you had a medical examination in the last year?
5. Do you use any prescription or non-prescription medicine including herbal remedies, regularly?
Specify
6. Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?
7. Do any allergic reactions result in headache, shortness of breath, chest constriction, nausea?
Specify:
8. Have you experienced any unusual reaction to any of the following?
Local anaesthesia (freezing)AspirinPenicillinIodineSulfonamideBarbiturates (sleeping pills)
or any other medicine? If so, explain:
9. Have you been warned against taking any drug or medication?
10. Do you have or have you ever had any of the following? (please check)
Heart murmur or mitral valve prolapseStomach/intestinal problemsJoint replacement (hip, knee, etc.)Mental or nervous disorderHigh/low blood pressureHyper(hypo) glycemiaEpilepsy or seizuresMalignant hyperthermiaDrug/alcohol addictionVenereal diseaseAny lung diseaseThyroid diseaseArthritis or rheumatismScarlet of rheumatic feverAIDSPositive testing for HIV virusJaundiceDiabetesTuberculosisStrokeHepatitis A/B/CHerpesHeart attackCold soresCancerKidney diseaseSinus troubleLiver diseaseCortisone/steroid therapy
Other:
11. Have you ever had any known contact with AIDS virus?
12. Has any member of your family has diabetes?
13. Do you bruise easily or bleed abnormally?
14. Do your ankles swell during the day?
15. Have you have any weight changes recently?
16. Do you have any blood disorders such as anemia (thin blood), thalassemia (major, minor)?
17. Have you ever had radiation treatment or chemotherapy?
If so, explain:
18. Have you ever had any injury, surgery or x-ray therapy to your face or jaws?
19. Do you have frequent severe headaches?
20. Do you have frequent earaches, ear/throat infections or any hearing difficulties?
21. Is your eyesight:
GoodAdequatePoor
Do you wear contact lenses?
22. Are you on a special diet?
23. Have you ever fainted?
24. Do you ever experience shortness of breath or chest pain when walking or climbing stairs?
Is so, explain:
25. Have you had any organ transplant or medical implants?
26. Do you have any disease, condition or problem that you think the doctor should know about?
27. Is there anything about yourself that we should be aware of?
28. WOMEN ONLY
Are you pregnant?
If so, which month are you in?
Are you taking any birth control pills?
1. Reason for today's visit:
ExamCleaningEmergencyOther
Is there a dental problem you would like to have taken care of as soon as possible?
2. How frequently do you see your dentist?
6 MonthsYearlyOther
Former dentist
Last dental visit
Last cleaning
Last full mouth series of x-rays
X-rays requested
3. Have you been given oral hygiene instruction in
BrushingFlossingOther
By whom?
4. Brushing:
VigorousLight
How often?
Type of brush?
5. How often do you floss your teeth?
6. Other cleaning aids used:
FlossStimudentsToothpickOther
7. Are any of your teeth sensitive to:
ColdSweetsHeatOther
8. Do your gums bleed when:
BrushingFlossingSpontaneously
9. Is your sugar intake:
HighMediumLow
10. Have you ever had or do you now have any of the following? (please check)
BridgesPartial denturesFull denturesRoot canal fillingsDental implantsLost fillingsExtractionsLoose teethOrthodontic treatmentBite adjustmentBite appliance/night guardSwelling or pain in your mouth or jawsInjuries to your face or jawsSurgery in your mouthGum treatmentsGag easilyDifficulty opening or closing your jaw
11. Do you chew on only one side of your mouth?
If so, why?
12. Does any part of your mouth hurt when clenched?
13. Does your jaw crack or pop when open widely?
14. Do you have any pain in your ears?
15. Have you experience any growth or sore spots in your mouth?
If so, where?
16. Do you grind or clenched your teeth during the day or night?
Do you
- grind or clenched your teeth during the day or night?
- mouth breath while awake or asleep?
- bite your lips or cheek regularly?
- hold any foreign objects with your teeth? (i.e. pipe, pencils, nails)
- smoke
CigarettesCigarsPipeOthers
No. per day
17. Check any of the following you are interested in or you have thought about:
Orthodontics (braces)Bonding (straightening)Closing spaces between teethReplacing missing teethRepairing chipped teethBleaching (whitening teeth)Crowns (caps)Sports mouth guardImproved gum healthImproving your biteImproving breath odorImproving your smile
18. Would you rate your current dental health as:
ExcellentGoodFairPoor
19. Do you have any emotional concern regarding your dental visit?
FearPainTimeMoneyEmbarrassment
Other concerns
I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.
PatientParentGuardian
Name (Required)