Date of Birth(required)
Carrier(eg. Blue Cross, Sunlife)
Reason for Visit
1. Are you in good health?
2. Have you been under the care of a physician during the last 2 years?
Condition being treated(Please Explain)
3. Date of last physical examination
4. Have you had any serious illness or operation?
5. Check any of the following which you have had or have at present:
Heart AttackStomach UlcersHepatitisRheumatic FeverChest PainDrug AddictionHeart SurgeryRheumatismPsychiatric TxKidney TroubleLiver DiseaseCongenital Heart LesionsAsthmaHemophillaHeart PacemakerEpilepseyNervousnessAids(HIV POS)Heart MurmurFaintingBlood TransfusionArtificial Heart ValveDiabetesArthritisLow Blood PressureHeart Disease or FailureTubercolosis(TB)Allergies or HivesRheumatic Heart DiseaseStrokeVenereal DiseaseHigh Blood PressureArtificial Joint
6. Have you had abnormal bleeding with extractions, surgery or trauma?
7. Are you allergic or have you reacted adversely to (select any of the following):
Local anaesthetic (Novocaine,lidocaine,freezing)
Penicillin or other antibiotics(Sulpha drugs, etc.)
Barbiturates, sedatives or sleeping pills
Aspirin or Tylenol(ASA or Acitaminophen)
Codeine or other narcotics
8. Are you taking any drug or medicine?
If so, what are you taking?
9. Have you had in the past or do you presently have any disease, condition or problem not listed above?
10. Women: Are you pregnant?
11. Do you smoke or have smoke in the past?
Dental History(Please check Yes or No)
1. Are you having any discomfort at this time?
2. Do you clench or grind your teeth?
3. Have you had an serious trouble or an anxious experience with any previous dental treatment?
4. How often do you clean your teeth? (Indicate times per day)
5. Do you use dental floss, toothpicks, mouthwash?
6. When did you last have your teeth cleaned? (Give approximate date)
7. Would you be disturbed if you had to loose teeth and wear false teeth?
8. Do you currently experience? (check any that apply)
Loose TeethHeadacheEaracheUnsatisfactory denturesProblem flossingSore gumsBleeding gumsNeck pain clicking in joint paint
9. Have you had?(check any that apply)
Orthodontics/BracesCrowns or BridgeTMJ or Bite ProblemsBite Plane / Night GuardPeriodontics / Gum TreatmentPartial Dentures
I understand that it is my responsibility to inform this office of any changes in my medical status. I also accept full responsibility for payment of my account regardless of any third party insurance involvement.