Please enter your sign-up information WELCOME TO OUR DENTAL OFFICE 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 commited to collecting, using and disclosing this information responsibly. REGISTRATION INFORMATION Last Name * First Name * Prefers to be called Salutation * Dr. Mr. Mrs. Ms. Miss The patient is an: AdultChildAdult under guardianship Name of Guardian: Language Preference Address: * City: * Province Home Phone: * Business Phone: Cell Phone: Email Address: Date of Birth: (mm/dd/yyyy) * Age: Sex: * Male Female How did you hear about our office? * Are other family members patients at our office? * YES NO MEDICAL PRIORITY This information will enable us to make any essential contacts. Family Physician: Phone: Medical Specialist: Phone: In case of emergency, please contact: Phone: DENTAL VISIT Reason for visit? Examination Emergency Other Other Is there a dental problem you would like treated immediately? MEDICAL HISTORY 1. Are you being treated for any medical condition at present or within the past two years? * YES NO If YES, please explain: Physician: Phone 2. Have you been hospitalized in past two years? YES NO 3. When was your last visit to a Physician? Last complete physical examination? 4. Have you recently, or are you presently, taking any presricption or non-prescription drugs, incl. herbal remedies? 1. 2. 3. 5. Have you ever reacted adversely to any of the following? Penicillin * YES NO Aspirin * YES NO Codeine * YES NO Local anaesthetic (freezing) * YES NO Other * 6. Have you ever been advised against taking any specific type of medications? 7. Do you have any of the following? Asthma * YES NO Hay Fever * YESNO Food Allergies * YESNO Metal or Latex Allergies * YESNO Skin Rashes * YESNO Hives * YESNO Any other allergic condition? 8. Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? If so, explain: 9. Is there a family history of Diabetes, Cancer or Heart Disease? * YESNO 10. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily? * YESNO 11. Do your ankles, feet or hands swell? * YESNO 12. Has your weight, appetite or energy level changed dramatically recently? * YESNO 13. Do you follow a special diet, or are you on a diet pil therapy? * YESNO 14. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? YESNO 15. Have you tested HIV positive? * YESNO 16. Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections? * YESNO 17. Have you ever had any injury or surgery to your face or jaws? * YESNO 18. Do you wear eyeglasses or contact lenses? * YESNO 19. Do you have any hearing difficulties? * YESNO 20. Do you smoke or use any other form of tobacco? * YESNO Are you wearing the transdermal nicotine patch? * YESNO 21. Are you alcohol and/or drug dependent? * YESNO and, Have you received treatment? YESNO 22. INDICATE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD: A.I.D.S. * YES NO Anemia * YESNO Angina pectoris * YESNO ARTHRITIS/rheumatism * YESNO Artificial heart valve * YESNO Artificial joints(hip, knee) * YESNO Blood disorders * YESNO Bronchitis * YESNO Cancer * YESNO Circulation problems * YESNO Congenital heart lesions * YESNO Cortisone/steroid * YESNO Crohn's disease * YESNO Diabetes * YESNO Emphysema * YESNO Epilepsy or seizures * YESNO Fainting or dizzy spells * YESNO Glandular disorders * YESNO Glaucoma * YESNO Head/neck injuries * YESNO Heart disease or attack * YesNO Hear murmur * YESNO Heart pacemaker * YESNO Heart rhytm disorder * YESNO Heart surgery * YESNO Hepatisis A B C * YESNO Herpes * YESNO High/Low blood pressure * YESNO Hodgkins disease * YESNO Hype (HYPO) Glycemia * YESNO Hypertension * YESNO Inflamatory bowel disease * YESNO Jaundice * YESNO Kidney disease * YESNO Liver disease * YESNO Lung disease * YESNO Lupus * YESNO Malignant Hyperthermia * YESNO Mental/nervous disorder * YESNO Mitral valve prolapse * YESNO Organ transplant/medical implant * YESNO Psychiatric treatment * YESNO Radiation treatment/chemotherapy * YESNO Scarlet fever - Rheumatic fever * YESNO Sickle cell disease * YESNO Sinus trouble * YESNO Stomach/intestinal problems/Ulcers * YESNO Stroke * YESNO Thyroid disease * YESNO Tuberculosis * YESNO Veneral disease * YESNO Other Other WOMEN ONLY 24. Are you pregnant or suspect you may be? YESNO Are you breast feeding? HEALTH QUESTIONS 25. Do you currently have, or have you had in the past, any disease, condition or problem not listed above? 26. Is there anything else about your health we should be made aware of? 26. Is there anything else about your health we should be made aware of? 27. Do you wish to speak privately to the doctor about any problem or medical condition? NOTE: IT IS IMPORTANT THAT ANY CHANGE IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE. DENTAL HISTORY Is there a dental problem you would like treated immediately? * YESNO If YES, explain: Date of your last dental visit? Last dental cleaning? Last x-rays? 1. Have you been seeing a dentists regularly? YESNO 2. Have you ever had any of the following? - Periodontal Treatment (treatment of gum) YESNO -Orthodontic Treatment (to straighten or realign teeth) YESNO - A bite plate or any other appliance? YESNO - A bite plate or any other appliance? YESNO -Your bite adjusted or teeth ground? YESNO -Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?) YESNO If you answered YES to the last question, who performed the surgery? When? Are you being followed up by a dental specialist? 3. Are there any growths or sore spots in your mouth? 4. Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums? YESNO 5. Have you noticed any loose teeth, or, do you suffer from pain or swelling of your gums? YESNO 6. Does food catch between your teeth? YESNO 7. Are there any of your teeth sensitive to heat, cold, sweets or pressure? YESNO 8. Have you been advised to take antibiotics before a dental appointment? YESNO 9. Do you use dental floss, proxabrush or stimundents? YESNO How often? 10. How often do you brush your teeth? Do you feel you have a bad breath? * 11. Have you experience any of the following jaw problems: - Popping / clicking in your jaw joints? YESNO - Pain in your jaw joints, around your ear, or side of your face? YESNO - Difficulty in opening or closing? YESNO - Pain when teeth are clenched? YESNO - Pain or difficulty while chewing? YESNO 12. Do you have any of the following habits? - Clenching or grinding your teeth while awake or asleep? YESNO - Bitting your cheeks or lips? YESNO - Mouth breathing while awake or asleep? YESNO - Placing foreigne objects in your mouth (pencils, nails, pipes, pins, fingernails)? YESNO and, 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 knowlingly omitted any information. Should there be any change in either my health status or any other information I have provided, I will advise thsi dental office. I authorize the dentists 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 dependants is mine, and I assume responsibility for fees associated with these services. Signature (to be signed in the office) I am * PatientParentGuardian If GUARDIAN, full name: Date (mm/dd/yyyy) * This is end of the form!