New Patient Form

    PERSONAL HISTORY & INFORMATION

    Patient's Name


    Pronouns
    He/HimShe/HerThey/Them
    Date of Birth













    INSURANCE INFORMATION





    *Payment is due at the time of the appointment unless other arrangements have been made*


    MEDICAL HISTORY

    1. Do you have current medical problem? Please check






    2. Have you ever had a serious injury or major operation in last 5 years?






    3. Are you presently being treated by a physician?






    4. Are you taking any medication, pill, drugs, or medicine?






    5. Do you smoke?




    MEDICAL ALERT

    The data contained in this confidential questionnaire is essential to render you our best professional care.

    We appreciate your cooperation in filling out this questionnaire carefully so that we will have accurate records.

    1. Do you now have or have you ever had any of the following? Please check
    Heart Trouble or StrokeHigh or Low Blood PressureTuberculosisDiabetesHepatitis, Jaundice, Liver DiseaseChest Pains, Shortness of BreathAsthma or AllergieArthritisDrug Allergies or ReactionsEpilepsy or SeizuresRheumatic FeverKidney DiseaseBleeding problems or DisordersSexually Transmitted DiseasesFrequent HeadachesCancerArtificial Joint Replacement SAVHIV






    2. Have you ever had an allergic reaction or side effect from any of the following? Please check:




    3. Is there anything else we should know about your health?





    4. Are you pregnant?





    DENTAL HISTORY

    1. What dental condition concerns you at present?




    2. When was your last visit to a dentist?




    3.When was your last cleaning?




    4. Do you have any sore, aching, or sensitive teeth?


    5. Do your gums bleed when brushing your teeth?




    6. Are you presently wearing partial or complete dentures?




    7. Do you grind or clench your jaws or teeth during the day or night?




    8. Have you ever had any complications with local anaesthetic (freezing)?




    9. Is there anything you would like to be done to improve the appearance of your teeth?




    10. Have you ever had orthodontic treatment (braces, etc.)?




    11. Have you ever visited a periodontist (gum specialist)?





    CONSENT

    Due to the precise nature of appointment scheduling, we charge the fee suggested by the B.C. Dental. Association for appointments missed or cancelled without 48 hours notice.





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