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?
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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