New Patiant Form 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 Name Last Name Gender - Select -MaleFemaleFamily Status - Select -MarriedSingleChildOtherDate of birth Email Phone Phone AddressAddress Line 1 City Province Postal Code How did you hear about us? Dental Office Drive by Staff Family or friends Internet Newspaper OtherName of person or other source of referral PreviousNextMEDICAL RECORD TRANSFERPlease allow us to get your past medical recordI, myself Ask 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 name Your primary care physician's phone Your primary care physician's addressAddress City Your physical conditionPlease select any of the following to indicate YES in response to the question Are 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 date Please select if any of the following apply to you Pre-medication-See notesAllergy-See notes Allergy-Aspirin Allergy-Codeine Allergy-Iodine Allergy-Latex Allergy-Penicillin Allergy-Sulfa Allergy-Erythromicin Allergy-Local Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Contraceptive Use Dental Phobia Diabetes Dizziness/Fainting Emphysema Epilepsy Excessive Bleeding Excessive Bruising Gastro-Intestinal Glaucoma Hard to Freeze Hay Fever HBP Head Injury Hearing Disabled Heart Disease Heart Murmur Hepatits A-B-CSpecify HIV+(AIDS) Hives Kidney Disease LBP Liver Disease Mental Disorders Multiple Sclerosis Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Rheumatoid Arthritis Sinus Problems Skin Rash Sleep Apnea STD Stomach Problems Stroke Thyroid Disease TMD Tuberculosis Tumors UlcersIf 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 you Do 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: Date First Name Last Name Previous Submit Form
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