NEW PATIENT Medical/Dental History
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Dental Information
How often do you brush your teeth?
How often do you floss your teeth?
Do your gums bleed while brushing or flossing?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Do you have frequent headaches?
Yes
No
Have you had periodontal (gum) surgery?
Yes
No
Have you had a head, neck, or jaw injury?
Yes
No
Are your teeth sensitive to cold, hot, sweets or pressure?
Yes
No
are you happy with the appearance of your teeth?
Yes
No
If, no, please explain.
Do you ever feel nervous about visiting the dentist?
Yes
No
If so, please explain.
if you have a current dental problem, please describe:
Date of your last cleaning:
Date of your last dental exam:
Date of your last dental x-rays? Please note if you have had x-rays taken within the last year we will be able to get them sent over and saved to your file! if you have not had x-rays taken within the last year we will take new ones at your first appointment.
Medical Information
Do you have a regular physician?
Yes
No
If so, please enter name, phone number, and date of last visit
Have you recently (in the last two years) been in the hospital or had a major operation? Please explain
Yes
No
Do you use any form of tobacco or are wearing a nicotine patch?
Yes
No
Do you take any recreational drugs?
Yes
No
Women Only
Are you or could you be pregnant?
Yes
No
if yes, what is the expected due date?
Are you taking birth control pills?
Yes
No
Do you wear contact lenses?
Yes
No
Do you have severe earaches, ear or throat infections, or headaches?
Yes
No
Other:
Medical conditions
AIDS/HIV positive
Yes
No
Anemia
Yes
No
Arificial Heart Valve
Yes
No
Arthritis/Rheumatism
Yes
No
Asthma
Yes
No
Blood Disorders
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Congenital Heart Lesions
Yes
No
Diabetes
Yes
No
Epilespy
Yes
No
Fainting
Yes
No
Heart Attack/Disease
Yes
No
Heart Murmur
Yes
No
Heart Surgery
Yes
No
Hepatitis A, B, or C
Yes
No
High Blood Pressure
Yes
No
Kidney Trouble
Yes
No
Liver disease
Yes
No
Lung disease
Yes
No
Mental/Nervous Disorder
Yes
No
Organ Transplant
Yes
No
Sinus Trouble
Yes
No
Stroke
Yes
No
Tuberculosis
Yes
No
Please enter details or any further information.
Please list all the medications (prescription or non-prescription) you are taking currently:
Are you allergic to or have you had a reaction to any of the following?
Barbiturates, sedatives, or sleeping pills
Yes
No
Anitbiotics
Yes
No
Aspirin
Yes
No
I certify that the above information is correct to the best of my knowledge
I authorize the doctor upon consultation and direct consent from the parient/parent/guardian to perform diagnostic procedures, treatment and medication with the patients dental needs
I understand that responsibility for payment of dental services, including insurance or otherwise, is due and payable at the time servies are rendered and despite any dental insurance, I am ultimately responsible for any fees not paid by my insurance company
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