Clarkson Smiles

PATIENT INFORMATION

Last Name

First Name

Middle Initial

Date D/M/Y

Age

Sex

Male Female

Home Phone

Work Phone

Mobile Phone

Street Address

City/Province

Postal Code

Email Address

Do you have dental insurance?

Yes No

REFERRAL INFORMATION

How did you hear about our office?

Do you have any other family members seen here?

IN CASE OF EMERGENCY PLEASE CONTACT

Name

Relationship to patient

Home Phone Number

Work Phone Number

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

2) Have you been hospitalized in the past two years?

Yes No

3) When was your last complete physical examination?

5) Have you recently, or are you presently taking PRESCRIPTION or NON-PRESCRIPTION drugs including herbal remedies?

6) Have you ever reacted adversely to any medications or injections?

7) Have you been advised against taking any specific medication?

Yes No

8) Do you have any allergies? If yes, please circle and explain below: Food, metal, LATEX

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

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

Yes No

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

Yes No

12) Do you have frequent severe headaches, earaches, ear/throat infection?

Yes No

13) Have you ever had an injury or surgery to your face or jaws?

Yes No

14) Do you have any hearing difficulties?

Yes No

15) Do you smoke or use any other forms of tobacco or the transdermal nicotine patch?

Yes No

16) Are you alcohol and/or drug dependent? If yes, have you received treatment?

17) WOMEN ONLY:

1) Is there a dental problem you would like treated immediately?

2) When was the last time you saw a dentist?

3) What was that appointment for?

4) Have you been seeing a dentist regularly?

Yes No

5) Have you ever had any of the following? Check all that apply:

Periodontal treatment (treatment of gums) Orthodontic treatment (realignment of teeth) Appliances such as a night guard, denture, bridge, etc. Your bite adjusted or teeth ground Dental anxiety Oral surgery (ex. jaw surgery or implant surgery)

6) Are there any growths or sore spots in your mouth?

Yes No

7) Do your gums bleed when brushing or eating?

Yes No

8) Do you suffer from pain or swelling of your gums?

Yes No

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

Yes No

10) Does food catch between your teeth?

Yes No

11) Are any of your teeth sensitive to heat, cold, sweets or pressure?

Yes No

12) Have you been advised to take antibiotics before a dental appointment?

Yes No

13) Do you use dental floss, proxabrush or stimudents?

14) Do you feel that you have bad breath?

Yes No

15) How often do you brush your teeth?

16) Have you ever experienced any of the following jaw problems? Check all that apply:

Popping/clicking in your jaw joints Pain in your jaw joints, around your ear, or side of your face Difficulty in opening or closing Pain when teeth are clenched Pain or difficulty while chewing

17) Do you have any of the following habits? Check all that apply:

Clenching or grinding your teeth while awake or asleep Biting your cheeks or lips Mouth breathing while awake or asleep Placing foreign objects in your mouth (pencils, fingernails, etc)?

18) Do you have any emotional concerns about having dental treatment?

Yes No

19) Are you unhappy with the appearance of your teeth?

Yes No

If so, what would you like to see changed?

20) Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or do you have any questions or concerns?

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