New Patients Step 1 of 10 10% The following information is required by the dentist to assist in proper diagnosis and treatment. Step One: Adult Patient or Parent (Guardian) RegistrationAre You The Patient Parent (Guardian) Are You Completing This Form For An Additional Child? Yes No Since you have already completed this form for a previous child, you only need to complete Steps 1, 3, 4, 8, 9 and 10Title Dr. Mr. Mrs. Ms. Miss Other Name First Last Address Street Address City Postal Code Date of Birth MM slash DD slash YYYY Age Sex Marital Status Home PhoneEmail Employer PhoneExtension Step Two: Physician InformationFamily Physician PhoneAddress Street Address City Postal Code Medical Specialist Step Three: Child Registration or Adult Under GuardianshipHow many children do you have? Please list all children who you will be completing forms forChild's Name to Whom This Form Is For First Last Prefers to be Called Address Street Address City Postal Code Date of Birth MM slash DD slash YYYY Age Sex Home PhoneSchool Grade Step Four: Account InformationPerson Responsible for Account Self Spouse Other (If Different From Main Page) Name First Last Home PhoneAddress (If Different From Step 1) Street Address City Postal Code Employer PhoneExtension Step Five: Spouse InformationSpouse's Name First Last Occupation Employer PhoneExtension In case of emergency Phone Step Six: Primary Dental InsuranceName of Insured First Last Date of Birth MM slash DD slash YYYY Employer Insurance Carrier Group/Policy Number Division Step Seven: Secondary Dental InsuranceName of Insured First Last Date of Birth MM slash DD slash YYYY Employer Insurance Carrier Group/Policy Number Division Step Eight: Medical History The following information is required by the dentist to assist in proper diagnosis and treatment1. Have you ever had a serious illness requiring hospitalization or extensive medical care? Yes Don't Know/Maybe No Specify 2. Are you presently under the care of a physician? Yes Don't Know/Maybe No If so, explain 3. Have you had a medical exam in the last year? Yes Don't Know/Maybe No 4. Do you use any prescription or non-prescription medicine regularly? Yes Don't Know/Maybe No Specify 5. Do you have any allergic condition: ie: asthma, hay fever, skin rash, food allergies? Yes Don't Know/Maybe No 6. Do any allergic reactions result in headache, shortness of breath, chest constriction, nausea? Yes Don't Know/Maybe No Specify 7. Have you been hospitalized in the last 5 years? Yes Don't Know/Maybe No 8. Have you ever experienced any unusual reaction to any of the following? Local anaesthesia (freezing) Aspirin Penicilin Iodine Sulfonmide Barbiturates (sleeping pills) Other medicine If so, explain 9. Have you been warned against taking any drug or medication? Yes Don't Know/Maybe No 10. Do you have or have you ever had any of the following? Heart murmur or mitral valve prolapse Stomach/intestinal problems Joint replacement (hip, knee, etc.) Mental or nervous disorder High/low blood pressure Hyper (hypo) glycemia Epilepsy or seizures Malignant hyperthermia Drug/alcohol addition Any lung disease Arthritis or rheumatism Scarlet or rheumatic fever AIDS Positive testing for HIV virus Jaundice Diabetes Tuberculosis Stroke Hepatitis A/B/C Herpes Heart Attack Cold sores Cancer Kidney disease Sinus trouble Liver disease Cortisone/steroid therapy Other 11. Have you ever had any known contact with the AIDS virus? Yes Don't Know/Maybe No 12. Do you bruise easily or bleed abnormally? Yes Don't Know/Maybe No 13. Do your ankles swell during the day? Yes Don't Know/Maybe No 14. Have you had any weight changes recently? Yes Don't Know/Maybe No 15. Do you have any blood disorders such as anemia (thin blood), thalassaemia (major, minor)? Yes Don't Know/Maybe No 16. Have you ever had radiation treatment or chemotherapy? Yes Don't Know/Maybe No If so, explain 17. Have you ever had any injury or x-ray therapy to your face or jaws? Yes Don't Know/Maybe No 18. Do you have frequent severe headaches? Yes Don't Know/Maybe No 19. Do you have frequent earaches, ear/throat infections or any hearing difficulties? Yes Don't Know/Maybe No 20. Is your eyesight Good Adequate Poor 21. Do you wear contact lenses? Yes Don't Know/Maybe No 22. Are you on a special diet? Yes Don't Know/Maybe No 23. Have you ever fainted? Yes Don't Know/Maybe No 24. Do you ever experience shortness of breath or chest pain when walking or climbing stairs? Yes Don't Know/Maybe No If so, explain 25. Have you had any organ transplants or medical implants? Yes Don't Know/Maybe No 26. Do you have any disease, condition or problem that you think the doctor should know about? Yes Don't Know/Maybe No If so, explain 27. Is there anything about yourself that we should be made aware of? Yes Don't Know/Maybe No If so, explain 28. WOMEN ONLY: Are you pregnant? Yes Don't Know/Maybe No If so what month are you in? 29. Are you taking any birth control pills? Yes Don't Know/Maybe No Is There Any Additional Information You Feel We Should Be Made Aware Of? Step Nine: Dental History1. Reason for today's visit Exam Cleaning Emergency Other Is there a dental problem you would like to have taken care of as soon as possible? 2. How frequently do you see your dentist? 6 months Yearly Other Former dentist Last dental visit 3. Have you been given oral hygiene instruction in Brushing Flossing Other 4. Brushing Vigorous Light Other How often? Type of brush? 5. How often do you floss your teeth? 6. Other cleaning aides used Floss Stimudents Toothpick Other 7. Are any of your teeth sensitive to Cold Sweets Heat Other 8. Do your gums bleed when Brushing Flossing Spontaneously 9. Is your sugar intake High Medium Low 10. Have you ever had or do you now have any of the following Bridges Partial dentures Full dentures Root canal fillings Dental implants Lost fillings Extractions Loose teeth Orthodontic treatment Bite adjustment Bite adjustment/night guard Swelling or pain in your mouth or jaws Injuries to your face or jaws Surgery in your mouth Gum treatments Gag easily Difficulty opening or closing your jaw 11. Do you chew on only one side of your mouth? Yes Don't Know/Maybe No 12. Does any part of your mouth hurt when clenched? Yes Don't Know/Maybe No 13. Does your jaw crack or pop when opened widely? Yes Don't Know/Maybe No 14. Do you have any pain in your ears? Yes Don't Know/Maybe No 15. Have you experienced any growth or sore spots in your mouth? Yes Don't Know/Maybe No 16. Do you - grind or clench your teeth during the day or night? Yes Don't Know/Maybe No Do you - mouth breathe while awake or asleep? Yes Don't Know/Maybe No Do you - bite your lips or cheeks regularly? Yes Don't Know/Maybe No Do you - hold any foreign objects with your teeth? (pipe, pencils, nails) Yes Don't Know/Maybe No Do you - smoke cigarettes cigars pipe other How Many Per Day? For How Long? 17. Check any of the following you are interested in or you have thought about Orthodontics (braces) Bonding (straightening) Closing spaces between teeth Replacing missing teeth Repairing chipped teeth Bleaching (whitening teeth) Crowns (caps) Sports mouth guard Improved gum health Improving your bite Improving breath odor Improving your smile 18. Would you rate your current dental health as Excellent Good Fair Poor 19. Do you have any emotional concerns regarding your dental visit Fear Pain Time Money Embarrassment Comments Step Ten: Informed ConsentI, the undersigned, state that I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding the Medical/Dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anaesthetic as may be necessary. I also understand that I assume responsibility for any and all fees associated with these procedures and services provided to me or my dependents.* I accept Patient (Parent, Guardian) Name* HiddenToday's Date MM slash DD slash YYYY
