Please enter your sign-up information
System information
Assigned to
*
Dr. Allen Aptekar
Dr. Doris Vengjen
Jo-Ann Hamilton
Alpine Dental Health Form Online
Patient Information
A parent or guardian will be responsible for decisions on my treatment
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Yes
No
I am
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Mr.
Mrs.
Miss
Ms.
Dr.
Single
Married
Widowed
First Name
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Initial
Last Name
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City
*
Address (#, Street, Apt.)
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Province
*
Postal Code
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Date of Birth (DD/MM/YYYY)
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Home Ph:
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Work Ph:
*
Cell Ph:
Do you have a Web phone?
Email:
Whom may we thank for referring you to our office?
Occupation:
Employer:
Emergency Contact:
Emergency Contact Ph:
Financial Information
Person responsible for financial matters:
*
Self
Spouse
Parent/Guardian
Other
Primary Insuarnce
Name of policy holder:
Ph:
Insurance Company:
Employer/Policy Holder:
Policy#:
Certificate#:
*
ID#:
Secondary Insurance:
Name of policy holder:
Ph:
Ins. Company:
Employer/Policy Holder:
Holder's Birth: (DD/MM/YYYY)
Policy#:
Certificate#:
ID#:
Dental History
1. What is the reason for today's visit?
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Emergency
Examination
Other
Explain other:
2. How frequently do you see a dentist?
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3-6 months
Annually
Other
Explain other:
3. When was your last dental visit?
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Last X-Ray?
4. How often do you brush per day?
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Floss?
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Yes
No
Use anti-bacterial rinse?
5. Are your teeth sensitive to:
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Cold
Sweets
Heat
Other
Explain other:
6. Do your gums bleed when:
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Brushing
Flossing
Never
7. Do your gums feel swollen or tender?
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YES
NO
8. Do you have a bad breath or bad taste in your mouth?
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YES
NO
9. Do your jaws crack, pop or grate when you open widely?
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YES
NO
10. Do you grind or clench your teeth?
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YES
NO
11. Do you have food catch between your teeth?
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YES
NO
12. Have you ever had local anaesthetic (freezing)?
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YES
NO
Any complications?
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YES
NO
If YES, specify:
13. Have you ever had any problems with previous dental treatments?
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YES
NO
If YES, specify:
14. have you ever had any of the following:
Bridgework
YES
Orthodontic (braces)
YES
Crowns or Caps
YES
Periodontal (Gums)
YES
Full or Partial Dentures
YES
Root Canal
YES
15. Are you satisfied with your teeth?
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YES
NO
If NO, specify:
Medical History
1. Are you presently under care of a physician?
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If YES, explain:
2. Have you been hospitalized?
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YES
NO
If YES, explain:
3. List any medication or drugs you are taking:
4. Have you ever had any adverse effect to any of the following:
Antibiotic - Penicilin
Sulfonamide
Other
Aspirin
Barbiturates (sleeping pills)
Codeine
Darvon
Local Anaesthetic
NONE
5. Have you ever been warned against using any other medications?
YES
NO
Which?
6. Have you ever taken prolonged medical or non-medical drugs?
YES
NO
Which?
7. Do you suffer from any allergies (hayfever, latex etc.)?
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YES
NO
Which?
8. Do you bruise easily or have prolonged bleeding?
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YES
NO
9. Do you smoke?
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YES
NO
If YES, how much per day?
10. Have you ever fainted, had shortness of breath or chest pains?
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If YES, explain:
11. WOMAN ONLY
Are you pregnant?
YES
NO
Using birth control?
YES
NO
Reached menopause?
YES
NO
12. Do you have or have you ever had any of the following? Please check appropriate boxes.
NONE
A.I.D.S
Anemia
Angina pectoris
Anorexia nervosa
Artificial Heart Valve
Arthritis/rheumatism
Artificial joints (hips,knees)
Asthma
Blood disorders
Bronchitis
Bulimia
Cancer
Circulation problems
Congenital heart lesions
Cortisone/steroid
Diabetes
Drug/alcohol dependence
Emphysema
Epilepsy
Glandular disorders
Glaucoma
Head/Neck injuries
Heart disease/attack
Heart murmur
Heart pacemaker/surgery
Heart rhytm disorder
Hepatisis A/B/C
Herpes
High/Low Blood pressure
H.I.V. Positive
Hodgkin disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
Kidney disease
Liver disease
Leukemia
Lung disease
Malignant hypothermia
Mental/nervous disorder
Mitral valve prolapse
Organ transplant/implant
Psychiatric disorders
Radiation/Chemotherapy
Rheumatic/Scarlet fever
Sickle Cell disease
Sinus trouble
Stomach/intestinal problems
Stroke
Thyroid disease
Tuberculosis
Ulcers
Veneral disease
Other
Other
GENERAL RELEASE
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowligly omitted data. I consent to release of the medical information from my medical doctor or other health care provider as is required by this dental office.
I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.
I am
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Patient
Parent/Guardian
Date:
Signature in the office:
Dentist name:
Signature of the dentist: