Full Name
Brithdate
Home Address
Postal Code
Home Phone
Cell Phone
Work Phone
Email
Emergency Contact
Relationship to Emergency Contact
Family Doctor (Clinic)
Family Doctor Phone or Address
Name of Medical Specialist
Phone
Place of Employment
Occupation
Who Referred you to our Office
Do you have Dental Insurance
If so, who is your Provider?
Pharmacy
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you being treated for any medical condition at the present or have you been treated with the past year?
If so, Why?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
If yes, please explain.
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
If yes, please provide list
Do you have any allergies?
If yes, please list below
Have you ever been treated for any communicable diseases?
If so, which ones?
Are you taking or have you ever taken Bisphosphonates/Bone loss medication?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Have you ever been treated or are you being treated for any mental health issues?
Do you have a prosthetic or artificial joint?
Any conditions or therapies that could affect your immune system, e.g. leukemia, AIDs?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
For women only: Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?
Are there any diseases or medical problems that run in your family? e.g. diabetes, cancer?
Do you have pain in your mouth while biting/chewing?
What is your main dental concern or complaint?
Do your teeth hurt because of heat, cold or sweets?
Do your gums feel tender or swollen?
Do you ever have clicking or tightness in your jaw?
Do you clench or grind your teeth?
Are you conscious of bad breath or bad taste?
Do you have any oral habits ie: nail biting, smoking, sucking fingers, tobacco chewing?
Have you ever had local anesthetic (freezing)?
Are you nervous about going to the dentist?
Do you like the way your teeth look?
Do you brush your teeth?
Do you floss your teeth?
Patient/Parent/Guardian Name
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