New Patient Intake Form - Tsawwassen Family Dental

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/ Insurance

2Medical History

3Dental History

Personal Information

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address City Province Postal Code

Phone*

Email*

Occupation

Employer

Dental Insurance

Do You Have Dental Insurance?*

Yes

Name of Insurance Plan

I.D. # or Certificate #

Policy Holders Employer

Dental Plan Holders Name

Policy Holders Date of Birth

DD slash MM slash YYYY

Policy or Plan Number

Dependent Number

Medical History

Personal Physician

Prefix First

Specialist

Prefix First

Phone

Address

Do 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 Medication

Are 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 Information

List All Medications, Supplements, and/or Vitamins Taken Within the Last Two Years

Reason for Taking

Describe Any Medical Treatment, Impending Surgery, or Other Treatment That May Possibly Affect Your Dental Treatment

Dental History

Referred By

First

Previous Dentist

Prefix First

How Long Have You Been a Patient

Date 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