• Dr. Tony Crivello DMD, MS, FRCD(C)
    Diplomate of American Periodontology
120 Torbay Rd, Suite W250, St. John’s NL A1A2G8

Patient Info

Name (required)

Date of Birth(required)

Marital Status

Address

Postal Code

Email Address

Occupation

Home Phone

Bus Phone

Spouse

Occupation

Bus Phone

Dentist

Town

How Long

Physician

Town

How Long

Dental Insurance
YesNo

Carrier(eg. Blue Cross, Sunlife)

Policy Number

Employer

Cert./Id #

Reason for Visit

Medical History

1. Are you in good health?
YesNo

2. Have you been under the care of a physician during the last 2 years?
YesNo

Condition being treated(Please Explain)

3. Date of last physical examination

4. Have you had any serious illness or operation?
YesNo

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?
YesNo

7. Are you allergic or have you reacted adversely to (select any of the following):
Local anaesthetic (Novocaine,lidocaine,freezing)
YesNo
Penicillin or other antibiotics(Sulpha drugs, etc.)
YesNo
Barbiturates, sedatives or sleeping pills
YesNo
Aspirin or Tylenol(ASA or Acitaminophen)
YesNo
Codeine or other narcotics
YesNo

Other(Please specify)

8. Are you taking any drug or medicine?
YesNo

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?
YesNo

10. Women: Are you pregnant?
YesNo

Month?

11. Do you smoke or have smoke in the past?

How much?

Dental History(Please check Yes or No)

1. Are you having any discomfort at this time?
YesNo

2. Do you clench or grind your teeth?
YesNo

3. Have you had an serious trouble or an anxious experience with any previous dental treatment?
YesNo

4. How often do you clean your teeth? (Indicate times per day)

5. Do you use dental floss, toothpicks, mouthwash?
YesNo

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?
YesNo

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.

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