New Patient Step 1: REGISTRATION INFORMATION This information will enable us to maintain communication with you. Medical Alert YesNo Date: I.D.#: The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly. The patient is an:AdultChildAdult under guardianship Name of Guardian: Your First Name Your Last Name Initial:Dr.Mr.Mrs.Ms.Miss Prefers to be called: Language Preference: Address: Apartment: City: Province: Postal Code: Home Phone: Additional registration information if required by office: Business Phone Ext: Employer: May we call you at work?YesNo Cell Phone: Pager No: Email Date of Birth Age: Sex: Marital Status: Name of Spouse: Preferred appointment time: Whom may we thank for referring you? Are other family members patients at our office?YesNo Family member name Please leave this field empty.Next Step 2: MEDICAL PRIORITY This information will enable us to make any essential contacts. Family Physician: Family Physician Phone Medical Specialist: (if presently under care) Medical Specialist Phone In case of emergency, please contact: Emergency Contact Number Nearest relative not living with you: Phone number Reason for today's visit?ExaminationnEmergencyOther Other reason Is there a dental problem you would like treated immediately? BackNext Step 3: FINANCIAL INFORMATION This information is necessary to process invoices and apply payments. Person responsible for account:SelfSpouseOther Please complete all information only if different than above. First Name Last Name Phone Address Apt.# City Province Postal Code Employed by: Phone: METHOD OF PAYMENT (For office use only)CashChequeCredit CardOther Additional financial information if required by office: BackNext Step 4: DENTAL INSURANCE (Complete information only if required by office) PRIMARY DENTAL INSURANCE Subscriber's name: Subscriber's D.O.B: Emp./Grp. policy holder. Insurance Year End Insurance Co. Insurance Tel Grp./Ind. policy No. Cert No. I.D # Max Coverage SECONDARY DENTAL INSURANCE Subscriber's name: Subscriber's D.O.B: Emp./Grp. policy holder. Insurance Year End Insurance Co. Insurance Tel Grp./Ind. policy No. Cert No. I.D # Max Coverage BackNext Step 5: DENTAL HISTORY (Please choose YES or NO to each question. If unsure of a question, please consult with the dentist.) Is there a dental problem you would like treated immediately? YesNo Details: Date of your last dental visit? Last dental cleaning? Last X-rays 1. Have you been seeing a dentist regularly? YesNo 2. Have you ever had Periodontal Treatment? ( treatment of the gums) YesNo Have you ever had Orthodontic Treatment YesNo Have you ever had a bite plate or any other appliance?YesNo Have you ever had your bite adjusted or teeth ground?YesNo Have you ever had oral surgery (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?)YesNo If you answered "yes", who performed the surgery? When was your surgery? Are you being followed up by a dental specialist? 3. Are there any growths or sore spots in your mouth? YesNo 4. Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?YesNo 5. Have you noticed any loose teeth, or, have any of your teeth shifted? YesNo 6. Does food catch between your teeth? YesNo 7. Are any of your teeth sensitive to heat, cold, sweets or pressure? YesNo 8. Have you been advised to take antibiotics before a dental appointment? YesNo 9. Do you use dental floss, proxabrush or stimudents? How often? YesNo How often you use dental floss, proxabrush or stimudents? 10. How often do you brush your teeth? Do you feel that you have bad breath?YesNo 11. Have you ever experienced any of the following jaw problems: Popping/clicking in your jaw joints?YesNo Pain in your jaw joints, around your ear, or side of your face? YesNo Difficulty in opening or closing?YesNo Pain when teeth are clenched?YesNo Pain or difficulty while chewing?YesNo 12. Do you have any of the following habits? Clenching or grinding your teeth while awake or asleep? YesNo Biting your cheeks or lips? YesNo Mouth breathing while awake or asleep? YesNo Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)YesNo 13.Do you have any emotional concerns about having dental treatment?YesNo 14. Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or, do you have any questions or concerns? 15. Are you unhappy with the appearance of your teeth? YesNo and, What would you like to see changed? 16. Do you feel your dental health influences your overall health? YesNo 17. On a scale of 1 to 10, 10 being highest, how important is it for you to keep your natural teeth? GENERAL RELEASE (Please sign after completing medical questionnaire.) 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. Signature (full name) PatientParentGuardian Reviewed by treating Dentist Date: *This form is protected by Copyright Law and may not be reproduced in whole or in part without the written consent of the copyright holder* BackNext Step 6: MEDICAL HISTORY (Please choose YES or NO to each question. If unsure of a question, please consult with the dentist.) 1. Are you being treated for any medical condition at present or within the past two years? YesNo If yes, please explain: Physician Physician Phone Number Have you been hospitalized in the past two years? YesNo When was your last visit to a Physician? Last complete physical examination? 4. Have you recently, or are you presently, taking any prescription or non-prescription drugs incl. herbal remedies 5. Hayou ever reacted adversely to any medications or injections? e.g.Penicillin, or otherantibiotics aspirin, codeine, local anaesthetic (freezing), nitrous oxide, or any other medicine: 6. Have you ever been advised against taking any specific type of medication? YesNo 7. Do you have any of the following? Asthma, Hay Fever, Food Allergies, Metal or Latex Allergies, Skin Rashes, Hives, or any other allergic conditions? 8. Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? YesNo If so, please explain: 9. Is there a family history of Diabetes, Cancer or Heart Disease? YesNo 10. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?YesNo 11. Do your ankles, feet or hands swell? YesNo 12. Has your weight, appetite or energy level changed dramatically recently?YesNo 13. Do you follow a special diet, or are you on a diet pill therapy?YesNo 14. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?YesNo 15. Have you or anyone in your family tested HIV positive or have Hepatitis A B C? YesNo 16. Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?YesNo 17. Have you ever had any injury or surgery to your face or jaws?YesNo 18. Do you wear eyeglasses or contact lenses?YesNo 19. Do you have any hearing difficulties?YesNo 20. Do you smoke or use any other forms of tobacco?YesNo Are you wearing the transdermal nicotine patch?YesNo 21. Are you alcohol and/or drug dependent?YesNo Have you received treatment?YesNo 22. INDICATE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD: A.I.D.S. YesNo AnemiaYesNo Angina pectoris YesNo Arthritis/rheumatism YesNo Artificial heart valve YesNo Artificial joints(hip, knee)YesNo Blood disorders YesNo Bronchitis YesNo Cancer YesNo Circulation problemsYesNo Congenital heart lesions YesNo Cortisone/ steroid YesNo Crohn's disease YesNo Diabetes YesNo Emphysema YesNo Epilepsy or seizuresYesNo Fainting or dizzy spells YesNo Glandular disorders YesNo Glaucoma YesNo Head/neck injuriesYesNo Heart disease or attack YesNo Heart murmurYesNo Heart pacemakerYesNo Heart rhythm disorderYesNo Heart surgery YesNo Hepatitis A B CYesNo HerpesYesNo High/Low blood pressureYesNo Hodgkins diseaseYesNo Hyper (Hypo) GlycemiaYesNo HypertensionYesNo Inflammatory bowel diseaseYesNo Jaundice YesNo Kidney diseaseYesNo Liver disease YesNo Lung diseaseYesNo LupusYesNo Malignant HyperthermiaYesNo Mental/nervous disorderYesNo Mitral valve prolapseYesNo Organ transplant/medical implantYesNo Psychiatric treatmentYesNo Radiation treatment/chemotherapy YesNo Scarlet fever -> Rheumatic feverYesNo Sickle cell disease YesNo Sinus troubleYesNo Stomach/intestinal problems/Ulcers YesNo StrokeYesNo Thyroid disease YesNo TuberculosisYesNo Venereal Disease YesNo Other: Other: Other: 23. Has the CHILD PATIENT recently had any of the following:(indicate approximate date.) Measles YesNo Mumps YesNo Chicken PoxYesNo Strep throat YesNo Tonsillitis YesNo 24. Do you currently have, or have you had in the past, any disease, condition or problem not listed above? 25. Is there anything else about your health we should be made aware of? YesNo 26. Do you wish to speak privately to the Doctor about any problem or medical condition?YesNo Women only: Are you pregnant or suspect you may Women be? YesNo Expected delivery date? Are you breast feeding?YesNo Are you taking any birth control pills?YesNo Women Over 50: Are you aware of your bone mineral density? YesNo Back
