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Date

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

Name

Prefers to be called

Language Preference

Address (Full residential address required) *

Please include city and post code.

Phone

Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.

Date of Birth

E-Mail

I consent to be contacted by Email if I have provided my Email address to the office.

Marital Status

Preferred Appointment Time

Whom may we thank for referring you?

Are other family members patients at our office?

Medical Information

Family Physician

Family Physician Phone

In case of emergency, please contact

Phone number

Reason for today's visit?

Health History

(Please answer yes or no. If unsure of a question, please consult with the dentist.)

Are you being treated for any medical condition at present or within the past two years?

YesNo

If yes, please explain

When was your last visit to a Physician?

Complete physical?

YesNo

Have you recently, or are you presently, taking any prescriptions or non-prescription drugs including herbal remedies?

YesNo

If so please list.

Have you ever reacted adversely to any medications or injections?

YesNo

If so please list.

Have you ever been advised against taking any specific types of medication?

YesNo

If so please list.

Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?

YesMaybeNo

Is there a family history of Diabetes, Cancer or Heart Disease?

YesNo

Do you bleed excessively from a cut or injury, or bruise easily?

YesNo

Do your ankles, feet or hands swell?

YesNo

Has your weight, appetite or energy level changed dramatically recently?

YesNo

Do you follow a special diet, or are you on a diet pill therapy?

YesNo

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?

YesNo

Have you tested HIV positive?

YesNo

Do you have frequent severe headaches, earaches, ear/throat infections?

YesNo

Have you ever had any injury or surgery to your face or jaw?

YesNo

Do you wear eyeglasses or contact lenses?

YesNo

Do you have any hearing difficulties?

YesNo

Are you wearing a transdermal nicotine patch?

YesNo

Are you alcohol and/or drug dependent?

YesNo

Do you smoke?

YesNo

If so, how many per day?

Other please specify

Have you recently had any of the following:

MeaslesMumps Chicken PoxStrep ThroatTonsillitis

Do you currently have, or have you had in the past any disease, condition or problem not listed above?

YesNo

If yes, please list

Is there anything else about your health we should be made aware of?

YesNo

If yes, please list

Do you wish to speak privately to the Dentist about any problem or medical condition?

YesNo

Women Only

Are you pregnant or suspect you may be?

YesNo

Expected delivery date

Are you breast feeding?

YesNo

Are you taking any birth control pills?

YesNo

Dental History

(Please answer yes or no, where applicable. If unsure, please consult with the dentist).

Is there a dental problem you would like treated immediately?

Date of your last dental visit

Last dental cleaning

Last dental x-rays

Have you been seeing a dentist regularly?

YesNo

What is your oral hygiene routine?

Have you ever had Teeth Whitening?

YesNo

Have you ever been told you snore loudly?

YesNo

If yes, does it affect your sleep?

Have you ever had any of the following?

Periodontal treatment (treatment of the gums)Orthodontic treatment (to straighten or realign teeth)A bite plate or any other applianceYour bite adjusted or teeth ground

Oral surgery and who performed and when?

Are you being followed by a dental specialist?

YesNo

Are there any growths or sore spots in your mouth?

YesNo

Do your gums bleed when brushing or eating?

YesNo

Do you suffer from pain or swelling of your gums?

YesNo

Have you noticed any loose teeth or have any of your teeth shifted?

YesNo

Does food catch between your teeth?

YesNo

Do you feel you have bad breath?

YesNo

Do you or have you experienced any of the following jaw problems?

Popping/clicking in your jaw jointsPain in your jaw joints, around your ear or side of faceDifficulty in opening or closing Pain when teeth are clenchedPain or difficulty while chewing

Do you have any of the following habits?

Clenching or grinding your teeth Biting your cheeks or lips Mouth breathing while awake or asleepPlacing foreign objects in your mouth

Do you have any emotional concerns about having dental treatment?

Are you unhappy with the appearance of your teeth?

and, what would you like to see changed?

Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment?

Do you have any questions or concerns?

I, 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/dental 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 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 will be collected, used and disclosed within the guidelines of the 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. *

Full Name *

Name of Guardian

Reviewed by Treating Dentist

Date *

PATIENT PRIVACY CONSENT: Privacy to your personal information is an essential part of our office providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. All staff members who encounter your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Please sign this consent form, we have outlined what our office is doing to ensure that: * Only necessary information is collected about you We only share your information with your consent * Storage, retention and destruction of your personal information complies with existing legislation, and privacy protocols * Our privacy protocols comply with privacy legislation, standards of our regulatory body and the law Do not hesitate to discuss our policies with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.

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