New Patient Form The following information is required by our office to thoroughly diagnose any condition and give you personal attention. This form is STRICTLY CONFIDENTIAL. Please fill out the form completely. "*" indicates required fields 1Personal Information/ Insurance2Medical History3Dental History Personal InformationName* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email* OccupationEmployerDental InsuranceDo You Have Dental Insurance?* Yes No Name of Insurance PlanI.D. # or Certificate #Policy Holders EmployerDental Plan Holders NamePolicy Holders Date of Birth DD slash MM slash YYYY Policy or Plan NumberDependent Number Medical HistoryPersonal Physician Dr. Prefix First Specialist Dr.Dr. Prefix First PhoneAddressDo You or Have You Ever Had? (Select All That Apply) hospitalization for illness or injury to take antibiotics prior to a dental procedure heart problems / defect / pacemaker heart murmur / ventricular prolapse rheumatic fever / scarlet fever high blood pressure low blood pressure a stroke artificial prosthesis anemia or other blood disorder abnormal bleeding emphysema tuberculosis asthma breathing or sleep problems (snoring, sinus, sleep apnea) sinus problems kidney disease liver disease jaundice thyroid or parathyroid disease hormone deficiency high cholesterol diabetes stomach or duodenal ulcer digestive disorders (gastric reflux) eating disorders (anorexia/bulimia) osteoporosis/osteopenia (taking bisphosphonates) arthritis glaucoma contact lenses head or neck injuries epilepsy, convulsions (seizures) neurologic problems /alzheimers / memory loss viral infections and cold sores any lumps or swelling in the mouth dry mouth hives, rash, hay fever venereal disease hepatitis HIV / AIDS tumor, abnormal growth radiation therapy chemotherapy emotional problems psychiatric treatment antidepressant medication alcohol/drug dependency Have You Ever Had an Allergic Reaction to: (Select All That Apply) aspirin, ibuprofen, acetaminophen penicillin erythromycin tetracycline codeine local anesthetic fluoride metals (gold, stainless steel) latex any other medications Name of MedicationAre you: (Select All That Apply) presently being treated for any other illness aware of a change in your general health often exhausted or fatigued subject to frequent headaches a smoker, smoked previously, use tobacco Female – taking birth control pills Female – pregnant /nursing Male – prostate disorders Additional Medical InformationList All Medications, Supplements, and/or Vitamins Taken Within the Last Two YearsReason for TakingDescribe Any Medical Treatment, Impending Surgery, or Other Treatment That May Possibly Affect Your Dental Treatment Dental HistoryReferred By First Previous Dentist Dr. Prefix First How Long Have You Been a PatientDate of Last Dental Exam/ Cleaning DD slash MM slash YYYY Date of Last Dental X-Rays DD slash MM slash YYYY Date of Last Treatment (eg. fillings, crowns, whitening) DD slash MM slash YYYY I Routinely See My Dentist Every (Select One Only)* 3 Months 4 Months 6 Months 12 Months Not Routinely How Would You Rate The Condition of Your Mouth (Select One Only)* Excellent Good Fair Poor How Often Do You Brush / Day?*How Often Do You Floss / Week?*How Often Do You Brush Tongue / Week?*What is Your Immediate Dental Concern? (Briefly Describe)*Dental History Details (Select All That Apply)Treatment History (Select All That Apply) Are you fearful of dental treatment? Have you had an unfavorable dental experience? Have you ever had complications from past dental treatment? Have you ever had trouble getting numb or reactions to local anesthetic? Did you ever wear braces, have orthodontic treatment or had your bite adjusted? Have you had any teeth removed? Smile Characteristics (Select All That Apply)If you are not happy with the appearance and function of your teeth, what would you change? Whiter teeth Straighter teeth Close spaces Lengthen teeth Contour / reshape teeth Replace metal fillings Repair chipped / broken teeth Replace missing teeth Repair worn teeth Replace old crowns / caps that don’t match Gum, Bone, and Tooth Structure (Select All That Apply) Are any teeth sensitive to hot, cold, biting, or sweets? Have you ever had a toothache, cracked filling, broken, chipped, or cracked tooth? Do you feel or notice any holes (ie. Pitting) in your teeth? Have you ever been diagnosed or treated for periodontal (gum) disease? Have you ever experienced gum recession? Is there a history of periodontal disease in your family? Do your gums bleed when brushing, flossing, or eating? Are your teeth becoming loose? Have you ever noticed an unpleasant taste or odor in your mouth? Have you experienced a burning sensation in your mouth? Bite & Jaw (Select All That Apply) Do you have any problems chewing gum or hard foods? Have your teeth changed in the last 5 years, become shorter, thinner or worn? Are your teeth crowding or developing spaces? Do you have more than one bite or do you clench (squeeze) your teeth to make them fit together? Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Do you have tension headaches or sore teeth? Do you wear or have you ever worn a bite appliance? (night guard) Date* DD slash MM slash YYYY Signature of Patient (or Parent/ Guardian)*I hereby certify that the information given here is complete, true and correctly recorded, and I consent to examination and treatment agreed to be necessary or advisable.CAPTCHA
