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New Patient Form

How did you hear about us? *

Name: *

First Name Middle Name Last Name

Sex: *

Date of Birth: *

Month Day Year

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Area Code Phone Number

E-mail:

Insurance Subscriber Information: If not same as above, please fill

Name:

First Name Last Name

Date of Birth:

Month Day Year

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Medical History

The following information is essential for proper diagnosis and treatment. Please read carefully and fill out completely. All information is confidential and cannot be released to anyone without your consent. You may choose to see our office’s privacy policy at any time.

Physician Name:

Physician address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Last visit:

Reason:

What medication(s) are you taking? *

Enter none, if you are taking no medication

What medication(s) are you ALLERGIC to: *

Enter none, if you have no allergies

Have you ever had ANY adverse reaction to or have been advised NOT to take any of the following medication(s)? *

Yes

No

NSAIDs

Aspirin

Codeine

Erythromycin

Penicillin

Tylenol

Local Anaesthetic

General Anaesthetic

Nitrous oxide (laughing gas)

Have you ever had ANY adverse reaction upon contact with the following? *

Yes

No

Sulphites (food preservatives)

PABA (sunscreen)

Latex (rubber gloves, balloons)

Nickel (costume jewellery)

Other Allergies? *

Enter none, if no allergies

Have you ever had, or been treated for, or do you currently have ANY of the following? *

Yes

No

Addiction

Allergy

Anaemia or blood disorders

Arthritis

Asthma

Cancer

Diabetes

Eating disorder

Epilepsy

Heart Attack, Coronary Disease or Heart Surgery

Heart Murmurs, Mitral Valve Prolapse or Rheumatic Fever

High/Low Blood Pressure

TB/Lung Disease

HIV(+)/AIDS

Hepatitis

Kidney Disease or Dialysis

Mental Illness, Anxiety or Depression

Prosthetic Valves, Joints or Plates

Sinusitis

Stroke

Thyroid problem

Ulcer

List ANY serious illness you have had: *

Enter none, if no serious illness

List ANY operations you have had: *

Enter none, if no operation

Have you ever fainted? *

Yes No

Do you experience shortness of breath on exertion? *

Yes No

Chest pains? *

Yes No

Do you require an extra pillow(s) when you recline or sleep? *

Yes No

If yes, how many?

Do your ankles swell? *

Yes No

If yes, what reason?

Has your weight changed recently? *

Yes No

If yes, how much?

Are you now or have you ever been on a diet? *

Yes No

If yes, what reason?

Do you bruise easily or bleed abnormally? *

Yes No

Is there any history of family disease? *

Yes No

If yes, please list

WOMEN ONLY: Are you pregnant?

Yes No

If yes, how many months?

WOMEN ONLY: Are you nursing?

Yes No

Dental History

Have you ever had any injury, surgery or radiation therapy on your face or jaws?? *

Yes No

If yes, please describe

Have you ever had complete set of x-rays or a "Panorex" taken? *

No

If yes, when?

When was your last dental visit? *

Purpose?

Were x-rays taken? *

Yes No

What dental condition(s) concern(s) have you at present? *

Have you had regular (annual or semi-annual) dental examinations in the past? *

Yes No

If no, please explain

Have you had ANY teeth extracted? *

Yes No

If yes, when?

Complications? *

Enter none, if no complications

Have you had local anesthetic before? *

Yes No

Describe any adverse reaction

Please answer these questions. *

Yes

No

Are you conscious of bad breath?

Are you conscious of bad taste?

Do your gums bleed, feel swollen or itchy?

Have you ever been instructed in the proper home care of your mouth?

Do you floss/rubber tip?

Are you TENSE during dental visits?

Have you ever had Nitrous Oxide (laughing gas) for any dental treatment?

Are you interested in discussing cosmetic options (changes to tooth color, shape, size, spacing or position)?

Do you chew easily and thoroughly? *

Yes No

Which side do you chew on? *

Right Left Not sure

Are you aware of clenching or grinding? *

Yes No

Does your jaw ever click, crack or lock? *

Yes No

If yes, which side?

Right Left

Does it ever get sore, stiff or painful? *

Yes No

Have you ever had TMJ therapy? *

Yes No

If yes, please describe

Are you satisfied with the appearance of your teeth? *

Yes No

What would you like to change?

Is there any other information which you think could be a factor in determining your treatment? *

Yes No

If yes, please explain:

Signature of Patient/Parent/Guardian *

Clear

Email (If you want to receive the copy of submitted form.)

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