New Patient Form

Salutation:

Dental Insurance YesNo

Is another member of your family a patient at our office YesNo

Any Heart Problems YesNo
Blood Pressure YesNo
Artificial Joints YesNo
Rheumatic Fever YesNo
Circulatory Problems YesNo
Radiation Treatment YesNo
Excessive Bleeding YesNo
Excessive Bruising YesNo
Ulcers (stomach) YesNo
Sinus Trouble YesNo
Artificial Heart Valves YesNo
Infectious Diseases YesNo
Allergies to Anaesthetics YesNo
Allergies to Penicillin YesNo
Allergies to Medications YesNo
Allergies to Latex YesNo
Anaemia or other Blood Disorders YesNo
Diabetes YesNo
Asthma YesNo
Hepatitis YesNo
Epilepsy YesNo
Liver or Kidney Problems YesNo
Tumour/Cancer History YesNo
Hormone Replacement Therapy YesNo
Are you currently taking any drugs or medicines? YesNo
Does your jaw "click" or hurt? YesNo
Do you feel you grind your teeth? YesNo
Have you ever had orthodontic treatment? YesNo
Do you wear a dental night guard? YesNo
Have you ever had periodontal (gum) treatment? YesNo
Have you ever had your bite adjusted? YesNo
Do you bite your lips or cheeks often? YesNo
Do you smoke? YesNo
Do you think you have occasional bad breath? YesNo
Do your gums ever bleed when you clean your teeth? YesNo
Do you experience sensitivity with hot/cold? YesNo
Do your teeth ever hurt when you bite hard? YesNo
Does floss ever tear between your teeth? YesNo
Does food get jammed between your teeth? YesNo
Is there anything else you would like us to know? YesNo

Are you pregnant? YesNo

How long since your last dental appointment?

How often do you have dental examinations?

Previous dental x-rays were taken Less than 1 yearMore than 1 year