Dentistry on Church Street
Welcome to our Practice
We look forward to becoming partners in your dental health care. Our approach to dentistry
is prevention oriented and is a team effort involving you and our staff. Together we will
address any current dental concerns and endeavor to prevent future dental problems.
Personal Information
Dr.
□ Mr. □ Ms. □ ____________________________
_____________________________
Last Name
Date of Birth
First Name
__________________________
Sex:
M
□
Address: ________________________________________________________
Street No.
________________,
City
Phone Number:
Street
F
□
_______
Apt.#
_______________
____________
Province
Postal Code
Home: (____)_______________
Work: (____)___________ Ext._____
Cell Phone: _(____)________________ Email Address : _________________________________
Family Physician __________________________________ Phone Number: _(____)_____________
Specialist: _______________________________________ Phone Number: _(____)_____________
Occupation _______________________
Employed by _________________________________
Who may we thank for referring you? _________________________________________________
Family member (s) in our practice? ____________________________________________________
Financial Information
□ Insurance □ Other □ ________
Person responsible for financial matters: Self □ Spouse □ Parent/Guardian □ Other: □ _____
Method of payment:
Cash
□
Cheque
□
Credit card
Dental Insurance:
Yes □
No □
Insurance Co. Name: __________________________________________________________
Group Policy Number: ___________________
Certificate or ID Number: __________________
Policy Holder’s Name: ______________________________ Date of Birth: _________________
1
Medical History
(All information gathered here, remains confidential)
(Please Circle)
Yes
No
1. Are you in good health?
2. When was your last complete medical examination? ____________________________
Yes
No
3. Are you presently under the care of a physician?
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
If Yes, please explain : ____________________________________________________
Have you been hospitalized in the last 2 years?
Yes
Are you taking any prescription or non-prescription medicines, regularly?
Yes
If yeas, please Specify : ___________________________________________________
Do you have any allergies? i.e. drugs, asthma, skin rash, food allergies or
Yes
latex
Please Specify: __________________________________________________________
Have you ever had an adverse reaction to dental freezing?
Yes
Do you have or have you ever had any of the following?
( Please circle )
Heart murmur, or other heart conditions
Heart Attack
Stroke
Venereal Disease
Stomach / intestinal problems Herpes Cancer
AIDS
Jaundice Tuberculosis
Mental or nervous disorders
Drug addiction Diabetes
Rheumatic Fever
joint replacement (hi, knee)
Kidney diseases
Liver diseases
Scarlet Fever
high / low blood pressure Sinus Trouble
Epilepsy / Seizures Arthritis / Rheumatism
Hypo / Hyper Glycemia
Thyroid Disease
Other: _________________________
Have you ever had any known contact with the AIDS virus?
Yes
Do you bruise easily or bleed abnormally?
Yes
Have you had any weight changes recently?
Yes
Do you have any blood disorders such as anemia (thin blood)?
Yes
Have you ever had any radiation therapy or chemotherapy?
Yes
If Yes, Please explain: ____________________________________________________
Have you ever had any injury, surgery, or x-ray therapy to your face or jaws?
Yes
Do you have frequent severe headaches?
Yes
Have you ever fainted?
Yes
Do you ever experience shortness of breath or pain in your chest when
Yes
walking or climbing stairs?
Have you ever had any organ transplant or medical /dental implant?
Yes
Do you have any disease, condition, problem not listed above that you think
Yes
the dentist should know about?
If Yes, Please explain: ____________________________________________________
WOMEN ONLY
20. Are you pregnant?
21.
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
If Yes, how many months? ________________________________________________
Are you taking any birth control pills?
Yes
No
Dr’s Notes----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Dental History
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What has brought you to our office today? _________________________________________
Are you having any dental discomfort at this time?
Yes
No
Where? ________________________________________________________________
How often do you visit your dentist? _________________________________________
When was you last visit?___________________________________________________
Are your gums bleeding?
Yes
No
When? _________________________________________________________________
Have you ever had any of the following: ( please circle all that apply)
Yes
No
Oral Surgery, Periodontal Treatment, Orthodontic Treatment, Bite Adjustment ,
Bite Plate or other appliances. Please Specify: ____________________________________
Do you have any dental implants?
Yes
No
Do you suffer from pain and / or swelling of your gums?
Yes
No
Do you chew on only one side of your mouth?
Yes
No
If Yes, why?
Yes
No
HABITS:
Do you grind or clench your teeth during the day or night?
Yes
No
Mouth breath while awake or asleep?
Yes
No
Bite your cheeks or lips regularly?
Yes
No
Hold any foreign objects with your teeth? i.e. pipe, pencils, nails
Yes
No
Does any part of your mouth hurt when clenched?
Yes
No
Does your jaw crack or pop when opened widely?
Yes
No
Do you have pain in your ears?
Yes
No
Have you ever experienced any growth or sore spots in your mouth?
Yes
No
If Yes where? __________________________________________________________
Are you concerned with the appearance of your teeth?
Yes
No
If yes what would you like to see changed? ________________________________________
_____________________________________________________________________
General Release
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history
and have not knowingly omitted any information. I have had the opportunity to ask questions and receive
answers to any questions regarding my medical - dental history. Should there be any change in either my health
status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform
diagnostic procedures as may be required to determine necessary treatment. I also give my consent to the
dentist to perform any treatment needed to improve my dental and oral health. I do realize that there are certain
risk involve in performing dental procedures. Hereby I release the dentist and Dentistry on Church Street from
any liability should any unwanted event happens as a result of the said procedure. I understand that information
provided from or to my medical doctor or another health care provider may be necessary. I have been advised
of the privacy policy of the office and that my personal information may be collected, used and disclosed within
the guidelines of the policy. I also give consent to give and get information regarding my insurance policy. I
understand that responsibility for payment of the dental services for myself and my dependents is mine, and I
assume responsibility for fees associated with these services.
X ___________________________ ____________ ________________________________
(Signature)
(Date)
(Print Your / Guardian Name)
Reviewed by Treating Dentist __________________________ Date: __________________
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