New Patient Form

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 committed to collecting, using and disclosing this information responsibly.

General Information

Are you the *
Salutation *
Person Responsible for Account

(Above information to be completed only if person responsible for account is other than self)

Dental Insurance

% of coverage

Medical Information

Reason for today's visit?

The following information is required by the dentist to assist in proper diagnosis and treatment.

Have you ever had a serious illness requiring hospitalization or extensive medical care?
Are you presently under the care of a physician?
Have you been hospitalized in the last 2 years?
Have you had a medical examination in the last year?
Do you use any prescription or non-prescription medicine including herbal remedies, regularly?
Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?
Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?
Have you ever experienced any unusual reaction to any of the following?
Have you been warned against taking any drug or medication?
Do you have or have you ever had any of the following? (please mark any/all that apply)
Have you ever had any known contact with the Aids Virus?
Has any member of your family had diabetes
Do you bruise easily or bleed abnormally?
Do your ankles swell during the day?
Have you had any weight changes recently?
Do you have any blood disorders such as anaemia (thin blood)?
Have you ever had radiation treatment or chemotherapy?
Have you ever had any injury, surgery or x-ray therapy to your face or jaws?
Do you have frequent severe headaches?
Do you have frequent earaches, ear/throat infections or any hearing difficulties?
Is your eyesight:
Are you on a special diet?
Have you ever fainted?
Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?
Do you have any medical or dental implants?
WOMEN ONLY - Are you pregnant?
Are you taking any birth control pills?

Dental History

How frequently do you see your dentist?
Have you been given oral hygiene instruction in:
Are any of your teeth sensitive to:
Do your gums bleed when:
Have you ever had any of the following:
Do you have any dental implants?
Do you suffer from pain and/or swelling of your gums?
Are you aware of any loose teeth?
Do you chew on only one side of your mouth?
Do you grind or clench your teeth during the day or night?
Do you mouth breathe while awake or asleep?
Do you bite your lips or cheeks regularly?
Do you hold any foreign objects with your teeth?
Does any part of your mouth hurt when clenched?
Does your jaw crack or pop when opened widely?
Do you have any difficulty in opening or closing your jaw?
Do you have any pain in your ears?
Do you gag easily?
Have you experienced any growth or sore spots in your mouth?
Are you concerned about the appearance of your teeth?
Would you rate your current dental health as:
Is your sugar intake:
Cleaning aids presently used:
Do you have any emotional concerns regarding your dental visit?

General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist 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 dependents is mine, and I assume responsibility for fees associated with these services.

By clicking submit you agree to certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care.

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