Patient Form

Welcome to Our Dental Office! Medical/Dental History Update

Mr.    Mrs.    Miss.    Ms.    Dr.

First Name
Last Name
Preferred Name

Date of Birth

Postal Code
E-mail ID
Home phone

   Male    Female.


Emergency Contact

Ins Company Name
Employer Name

Dental Policy/Group #

Who may we thank for referring you to us?

Dental History
Have you ever had a negative dental experience?
Yes    No
Please explain

Are you generally tense during dental visits?
Yes    No

Periodontal History
Are you aware of bad breath or a bad taste in your mouth? Yes    No

Does food routinely get wedged between your teeth? Yes    No

Does your mouth tend to be dry? Yes    No

Are your parents or siblings missing any of their natural teeth? Yes    No

Do you smoke cigars or cigarettes? Recreational smoking? (circle all that apply) If so, how many?    
Do you chew on pencils, gum, ice cubes, or popcorn kernels? Etc.(circle all that apply) Yes    No
Do you bite your fingernails, pins, or use a pipe? Etc. (circle all that apply) Yes    No

Do you drink coffee, tea, or cola drinks? (circle all that apply) Yes    No
How often?     

Do you bite your lips or cheeks regularly? Yes    No

Do you breathe through your mouth when awake or asleep? Yes    No

Do you snore during sleep? Yes    No

Do you participate in any sports? Yes    No
If so, what kind?     

Are you satisfied with the appearance of your teeth and smile? Yes    No

Would you be interested in knowing more about veneers, bonding, tooth whitening, implants, other cosmetic options? Yes    No

If you could wave a magic wand, what would you change about your smile?     

Medical History
Are you in good health Yes    No   

When was your last complete medical examination? Select Date

Have you ever been hospitalized for a serious illness or operation? Yes    No

If so, Please explain
Are you currently taking any prescription or non-prescription medication? Yes    No

If yes, please list
Do you have any allergies? Including: Medications, foods, latex, environmental, other? Yes    No
If yes, please list
Have you ever had a previous reaction to metal or metal jewellery? Yes    No

Have you ever had an adverse reaction to dental freezing, general anaesthetic, penicillin, codeine, aspirin, or other drugs? Yes    No

If yes, what kind of reaction?
Do you suffer from canker sores or cold sores? Yes    No

Are you subject to prolonged bleeding, and/or do you bruise easily? Yes    No

Have you ever fainted? Yes    No

What were the circumstances?
Have you ever experienced any recent unexplained weight change, or increased thirst, appetite, or frequency of urination? Yes    No

Have you ever had a shortness of breath or pains in your chest? Yes    No

Have you had or ever been treated for rheumatic fever, rheumatic, or congenital heart disease? Yes    No

Do you have a heart condition of any kind? (angina pectoris, arrhythmias, or previous heart attack – please circle) Yes    No

Has your physician ever told you that you have a heart murmur or mitral valve prolapse? Yes    No

Have you had any organ transplants or joint replacements? Yes    No

If Yes, When
Do you have a prosthetic heart valve or wear a pacemake? Yes    No

Have you been told by your medical doctor that you need to take antibiotics before dental treatment? Yes    No

Have you ever been treated for Hepatitis? Yes    No

Which Type
Do you have or have you had any of the following diseases or conditions? (please circle all that apply) Yes    No

Anaemia or blood disorders
High or low blood pressure
Tuberculosis or Asthma
Emphysema or other lung disease
Deafness or Blindness
Kidney or Liver disease
Venereal disease
Mental or nervous disorders
Epilepsy or Seizures
Down syndrome or Cerebral Palsy
Sinus or Nasal problems
Diabetes, Hyper or Hypoglycemia
Alzheimer’s or Parkinson’s
Thyroid Disease
Multiple Sclerosis
Ulcers or other stomach disorders
Arthritis or Rheumatism
Gall bladder disorders
Attention Deficit Disorder
Eczema or Psoriasis
Are you on any special diet? (e.g. salt restricted diet) Yes    No

Do you wear contact lenses? Yes    No

Are you pregnant? If yes, how many months? Yes    No

Are you taking birth control pills? Yes    No

Are you menopausal or post-menopausal? If yes, are you on hormone replacement therapy? Yes    No

On a scale of 1 to 5, please rate your current dental health:    Excellent   1    2    3    4    Very Poor

What priority do you place on your dental health?    Highest Priority   1    2    3    4    Lowest Priority

I, the undersigned, certify that all of the above medical and dental information is true to the best of my knowledge and I have not omitted any pertinent information. Should the need arise, I allow my medical doctor to be consulted. I understand that I am financially responsible to the dentist for all necessary treatment.