Patient Information

your cooperation in filling out the data on this confidential questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain with this office.
Name :
Dr. Mr. Mrs. Ms.

Age :
Sex :
Marital Status :

Address :

Home Phone :
Date of Birth :

Occupation :
Email :

Employed By :
Bus Phone :

Dental Insurance :
Name Of Company :

Ins Policy No. :
Health Ins No. :
% Covered :

Family Physician :
Phone No. :
Previous Dentist :

Whom May We Thank For Referring You? :

In Case Of Emergency Notify :
Name :
Address :

Relationship :
Phone No. :

Person Responsible For Account :

Name :
Address :
Telephone :

Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require TWO BUSINESS DAYS notice, in order to avoid a lost fee. Office policy is that services are paid for at each visit as they are performed. However in Certain circumstances arrangements for payment may be made by consulting our Practice Co-Ordinator.

1.Date of last physical examination? :

Are you presently under the care of a physician? :
Please specify :

Are you presently taking any pills, drugs or medication? :
Please specify :

Have you taken any prolonged medication in the past? Prescription or Non-prescription? :
Please specify :

Have you had rheumatic fever? :
Do you have heart disease or murmur? :
Do you become breathless easily? :

Have you had abnormal bleeding? :
Have you taken cortisone or steroids? :

Have you any allergies? Ie. Food, pollen :
Please specify :

Have you allergies to any drugs or medicines? Ie. Penicillin :
Please specify :

Have you ever been hospitalized and was surgery performed? :
Please specify :

Are your ankles often swollen? :
Have you gained or lost excessive weight recently? :
Have you ever had radiation or x-ray therapy? :

Do you have or had?
High Blood Pressure
Low Blood Pressure
Nervous Problems
Thyroid Problems
Are you Pregnant
Heart Trouble
Chest Pain
Liver Trouble
Blood Disorders
Psychiatric Care
Venereal Disease
Scarlet Fever
Sinus Problems
Fainting Spells
Kidney Trouble

Is there anything else you think you should tell me? :
Please specify :

Are you currently in good health? :
Are you pregnant? If so, what month? :

Confidential Dental History
Are you having any discomfort at this time? :
Please specify :

Have you been under regular care by a dentist? :
How long since your last dental visit? :

What was done at that time? :

Do your gums feel tender or swollen? :
Have you ever been given local anaesthetic (freezing)? :

Have you ever been give general anaesthetic? :
Any complications?, Please specify :

Are you aware of any lump or swelling in your mouth? :
Are you satisfied with the appearance of your teeth? :
Are you anxious to keep your natural teeth? :

Are you tense during dental visits? :
Are you interested in a method to calm your nerves? :

Describe in your own words what you would like done with your teeth :

Do you currently experience (Circle the appropriate ones)
Loose teeth
Sensitive teeth
Ear ache
Spaced or crooked teeth
Bleeding gums
Bad breath
Neck pain
Unexplained nosebleed
Unsatisfactory dentures
Sore gums
Popping or clicking in the jaw joints
Missing teeth

Upon arrival to our office, you will be notified to sign the consent form for the treatment.