Patient Info Patient InfoDental Implants Teeth In A Day Oral Plastic Surgery Periodontal Treatment Bone Grafting Impacted Teeth Oral Pathology Your Appointment Patient Forms FAQ’s After Treatment Care Name (required) *Date of Birth(required) *Address *Marital Status *Postal Code *Email AddressOccupation *Home Phone *Bus Phone *Spouse *Occupation *Bus Phone *Dentist *Town *How Long *Physician *Town *How Long *Dental InsuranceYesNoCarrier(eg. Blue Cross, Sunlife) *Policy Number *Employer *Cert./Id # *Reason for Visit1. Are you in good health?YesNo2. Have you been under the care of a physician during the last 2 years?YesNoCondition being treated(Please Explain)3. Date of last physical examination4. Have you had any serious illness or operation?YesNo5. 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 Joint6. Have you had abnormal bleeding with extractions, surgery or trauma?YesNoLocal anaesthetic (Novocaine,lidocaine,freezing)YesNoPenicillin or other antibiotics(Sulpha drugs, etc.)YesNoBarbiturates, sedatives or sleeping pillsYesNoAspirin or Tylenol(ASA or Acitaminophen)YesNoCodeine or other narcoticsYesNoOther(Please specify)8. Are you taking any drug or medicine?YesNoIf 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?YesNo10. Women: Are you pregnant?YesNoMonth?11. Do you smoke or have smoke in the past?How much?1. Are you having any discomfort at this time?YesNo2. Do you clench or grind your teeth?YesNo3. Have you had an serious trouble or an anxious experience with any previous dental treatment?YesNo4. How often do you clean your teeth? (Indicate times per day)5. Do you use dental floss, toothpicks, mouthwash?YesNo6. 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?YesNo8. Do you currently experience? (check any that apply)Loose TeethHeadacheEaracheUnsatisfactory denturesProblem flossingSore gumsBleeding gumsNeck pain clicking in joint paint4. Have you had any serious illness or operation?Orthodontics/BracesCrowns or BridgeTMJ or Bite ProblemsBite Plane / Night GuardPeriodontics / Gum TreatmentPartial DenturesSubmit
