First Name

Last Name

Status

Single

Married

Child

Other

Date of Birth

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Work Tel

Home Tel

Physician

Previous Dentist

Why have you decided to change dental offices?

How did you hear about us?

Name of insured if different from above:

Employer

Date of Birth of Insured

Insurance Company

Policy/Group

Division (If applicable):

Certificate ID#:

Division (If applicable):

Do you have Secondary Insurance?

Yes

Name

Relationship:

Tel

Are you being treated for any medical condition at the present or have you been treated within the last year? If yes, specify:

Yes

When was your last medical check-up?

Has there been any change in your general health in the past year?

Are you taking any medications or non-prescription drugs of any kind? If yes, please list them below:

Do you have any allergies?

Have you had an unusual reaction to any drugs or medicines?

Penicillin

Sulfonamide

Aspirin

Codein

Local Anesthetic

Have you taken Oral/ IV Bisphosphonates medications? or are you still taking them?

Do you have a bleeding problem or bruise easily? Are you on blood thinner?

Do you have any conditions that could affect your immune system ego AIDS, HIV infection, Leukemia etc?

Do you smoke? If yes, how much?

Have you ever been hospitalized for any serious illnesses or operations?

Do you have or have you ever had any of the following?

Chest Pain/Angina

Heart Attack

High Blood Pressure

Emphysema

Asthma

Epilepsy

Thyroid Disease

Kidney Disease

Cancer

Chemotherapy/Radiation

Psychiatric Disorder

Tuberculosis

Arthritis

Steriods

Cortisone

Stomach Ulcers

Diabetes

Drug/Alcohol Dependency

Stroke

Sinus Problems

Organ Transplant

Heart Murmur

Mitral Valve Prolapse

Pacemaker

Jaundice

Hepatitis

Liver Disease

Prosthetic Joints

Artificial Joints

Rheumatic Fever

For females: Are you pregnant or breast feeding? Any other conditions or problems of which the dentist should be aware of? If yes, please list: _

Pain in your jaw joints, around your ear, orside of your face?

Yes

Popping/clicking in your jaw joints?

Yes

A bite plate or any other appliance?

Yes

Difficulty in opening or closing?

Yes

Pain or difficulty while chewing?

Yes

Clenching or grinding your teeth while awake or asleep?

Yes

Biting your cheeks or lips?

Yes

Mouth breathing while awake or asleep?

Yes

Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?

Yes

Periodontal Treatment? (treatment of the gums)

Yes

Orthodontic Treatment? (to straighten or realign teeth)

Yes

A bite plate or any other appliance?

Yes

Your bite plate or any other appliance?

Yes

When was your last dental visit?

When did you last have dental x-rays?

How often do you brush your teeth?

How often do you floss your teeth?

Have you been seeing a dentist regularly?

Yes

Do any of your teeth ache?

Yes

Have you ever been advised to take antibiotics before dental appointments?

Yes

Do your gums bleed when you brush?

Yes

Do you have any pain when you chew?

Yes

Do you feel that you have bad breath?

Yes

Have you ever been in a motor vehicle accident or experienced any blows to your jaw?

Yes

Have you ever had a dental implant surgery?

Yes

If yes, who performed the surgery and when was it done?

Yes

Are you being followed-up by a dental specialist?

Yes

Please list anything else not mentioned above regarding your past dental history:

I UNDERSTAND that in order to get my examination

You will be asked about medical history, dental history, current and previous, Chief complaint, goals of the treatments. You will disclose the current accurate information to the best of your knowledge.
All information you share is confidential, only necessary information is collected about you.
I only share your information with your consent.
Storage, retention and destruction of your personal information complies with existing legislation, and privacy.
Privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons.
Extra oral exam, Intra oral exam, elective Oral cancer screening, TMJ assessment, Dental Occlusion Assessment, Specific Exam, or Second opinion are all procedures that need the use of sterilized dental instruments that will be used during the exam. You have the right to deny use of any instruments. You have the right to ask all the questions about different procedures and getting them explained to you before they are conducted.
Collecting additional information such as, dental casts or impressions, x-ray or other means of imaging, photography, Referral to other specialists such as and not limited to: Periodontists, Endodontists, Orthodontists, Oral medicine, Oral anaesthesia, Maxillofacial Surgeon and Physician is needed to formulate accurate diagnoses and you will be informed about them as needed. You have the right to deny any of those data collections procedures.
You authorize photos, slides, and x-rays of my care and treatment during or after its completion to be used for the advancement of dentistry and for reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.

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