New Patiant FormPatient initial form (EN)PATIENT INFORMATIONMEDICAL RECORD TRANSFERMEDICAL AND DENTAL HISTORYPATIENT INFORMATIONPlease take a moment to enter your information in order to help us ensure the quality of your careFirst NameLast NameGender- Select -MaleFemaleFamily Status- Select -MarriedSingleChildOtherDate of birthEmailPhonePhoneAddressAddress Line 1CityProvincePostal CodeHow did you hear about us? Dental Office Drive by Staff Family or friends Internet Newspaper OtherName of person or other source of referralPreviousNextMEDICAL RECORD TRANSFERPlease allow us to get your past medical recordI, myselfAsk of Dr. / Medical office:to release my/our following dental records. Dates and copies of my/or last: New patient exam Scaling and root planing Bitwing X-rays Panoramic X-rayPreviousNextMEDICAL AND DENTAL HISTORYPlease take a moment to let us know about your medical/dental history so we may serveyou more efficiently and in a way that looks out for your overall health and well being.Can you tell us how anxious you get, if at all, with your dental visits?Please indicate by checking off the appropriate box1. If you went to your DENTIST FOR TREATMENT TOMORROW, how would you feel? Not Anxious Slightly Anxious Fairly Anxious Very Anxious Extremely Anxious2. If you were SITTING IN THE WAITING ROOM (waiting for treatment), how would you feel? Not Anxious Slightly Anxious Fairly Anxious Very Anxious Extremely Anxious3. If you were about to have a TOOTH DRILLED, how would you feel? Not Anxious Slightly Anxious Fairly Anxious Very Anxious Extremely Anxious5. If you were about to have a LOCAL ANAESTHETIC INJECTION in your gums, above an upper back tooth, how would you feel? Not Anxious Slightly Anxious Fairly Anxious Very Anxious Extremely Anxious4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel? Not Anxious Slightly Anxious Fairly Anxious Very Anxious Extremely AnxiousWould you consider yourself to be in good health?- Select -YesNoWithin the last year, have there been any changes in your general health?- Select -YesNoWhat is the date (or approx. date) of your last medical exam?Your primary care physician's nameYour primary care physician's phoneYour primary care physician's addressAddressCityYour physical conditionPlease select any of the following to indicate YES in response to the questionAre you currently under the care of a physician due to a specific condition?Have you been hospitalized within the last 5 years due to surgery or illness?Are you currently taking any prescription or non-prescription medications?Do you use tobacco? (smoking or chewing)Do you require the use of corrective lenses? (contacts or glasses)Do you have any other conditions, diseases, etc, not listed above that we should be made aware of?If any of the previous questions are marked, please explain:(for women only) Are you pregnant? Yes NoDue datePlease select if any of the following apply to youPre-medication-See notesAllergy-See notesAllergy-AspirinAllergy-CodeineAllergy-IodineAllergy-LatexAllergy-PenicillinAllergy-SulfaAllergy-ErythromicinAllergy-LocalAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerContraceptive UseDental PhobiaDiabetesDizziness/FaintingEmphysemaEpilepsyExcessive BleedingExcessive BruisingGastro-IntestinalGlaucomaHard to FreezeHay FeverHBPHead InjuryHearing DisabledHeart DiseaseHeart MurmurHepatits A-B-CSpecifyHIV+(AIDS)HivesKidney DiseaseLBPLiver DiseaseMental DisordersMultiple SclerosisNervous DisordersPacemakerRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismRheumatoid ArthritisSinus ProblemsSkin RashSleep ApneaSTDStomach ProblemsStrokeThyroid DiseaseTMDTuberculosisTumorsUlcersIf there is one thing you would like to change about your smile, what would it be?What is the main reason for your visit with us today?What was done on your last dental visit?Previous Dentist name, address & phone number:How frequently do you brush your teeth? 3 + times/day Twice/day Once/day Weekly SeldomHow frequently do you floss your teeth? 1+/day 2-6 times/weekly 1-6 times/month Seldom NeverPlease select if any of the following apply to youDo your gums bleed when you brush?Do your teeth experience sensitivity to cold or hot temperatures?Are any of your teeth currently causing you pain?Do you grind your teeth? (consciously or during sleep)Are any of your teeth loose or are you concerned about teeth loosening?Do you currently have any dental implants, dentures or partials?If any of the previous questions are marked, please explain:DateFirst NameLast NamePreviousSubmit Form
