905-457-4445    onqueen@mysmiledentistry.ca   
Select Location : Brampton

New Patient Form Print Form

Welcome to Our Dental Office!

Mr.    Mrs.    Miss.    Mrs.    Ms.    Dr.
   Adult.    Child.

Name
Prefer to be Called
Address

Home phone
Work phone
Date of Birth

Fax
Other
   Male    Female.

Employer/School
Occupation
E-mail ID

Who may we thank for referring you to this office?

Are you likely to be available on short notice for future appointments or appointment changes?

Yes    No

Family Physician
Phone

In Case of Emergency Notify
Relation
Phone

Person responsible for this account :
Self    Spouse    Parent    Legal Guardian   

Other

Primary Insurance

Subscriber
Relation Self    Spouse   
Other

Insurance Co

Policy/Plan No.
Division/Sect No.

Subscriber I.D
SIN

Are You Familiar with Your Plan Details?     Yes    No

Secondary Insurance

Subscriber
Relation Self    Spouse   
Other

Insurance Co

Policy/Plan No.
Division/Sect No.

Subscriber I.D
SIN

Are You Familiar with Your Plan Details?     Yes    No

Method of Payment Cash    Cheque    Credit Card   
Number


Exp.


MEDICAL HISTORY Yes    No    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?
Please specify

Are you presently under the care of a physician?
if so, please explain

Have you had a medical examination in the last year?

Do you use any prescription or non-prescription drugs regularly?
Please specify

Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex?

Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?
Please specify

Have you been hospitalized in the last 5 years?
Please specify

Have you ever experienced any unusual reaction to any of the following? (Please circle) local anesthesia (freezing), aspirin, penicillin, codeine, sulpha drugs, barbiturates (sleeping pills), or any other medicine?
If so please explain

Have you been warned against taking any drug or medication?

Do you bruise easily or bleed abnormally?

Have you ever had any organ implants or medical implants? Yes    No

Have you ever fainted? Yes    No

Do your ankles swell? Yes    No

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? Yes    No

Do you have frequent headaches? Yes    No

Do you have A.I.D.S. or have you ever tested positive for H.I.V.? Yes    No

Do you have any of the following? Please check any that apply Yes    No

Heart Murmur or mitral Valve Prolapse
Stomach / Intestinal Problems / Ulcers
Joint Replacement (hip, knee, etc.)
Dental or Nervous Disorder
Blow Blood Pressure
Hyper (hypo) Glycerin
Epilepsy or Seizures
Carlson / Steroid Therapy
Malignant Hyperthermia
Drug / Alcohol Dependency
Venereal Disease
Lung Disease (i.e. Asthma)
Thyroid Discase
Arthritis or Rheumatism
Scarlet or Rheumatic Fever
Cancer / Chemotherapy
Liver Disease
Heart Attack
Cold Sores
Jaundice
Diabetes
Tuberculosis
Hepatitis A,B,C
Herpes
Sinus Trouble
Stroke
Kidney Problems
Emphysema
Glaucoma
Others





Have you had any injury, surgery or x-ray therapy to your face or jaws? Yes    No

Do you have any disease, condition or problem that you think the doctor should know about? Yes    No

WOMEN ONLY

Are you pregnant or suspect you might be? If so, what month are you in? Yes    No

Are you taking birth control pills? Yes    No

Are you nursing? Yes    No

DENTAL HISTORY

Reason for today’s visit: Exam    Cleaning    Emergency
Others

Are you presently having dental pain? Yes    No

Is there a dental problem you would like to take care of as soon as possible? Yes    No
Please specify

How tranquilly do you see your dentist? 6 months    Yearly
Other

Former dentist
Last dental visit
Last cleaning
Full mouth series of x-rays
How often do you brush your teeth?
Floss?



Do your gums bleed easily? Yes    No

Are your teeth sensitive to Hot    Cold    Biting    Sweets


Do you feel you have bad breath at times? Yes    No

Have you ever had jaw joint surgery? Yes    No

Do you have pain in your jaw joints or suffer from migraine headaches? Yes    No

Does any part of your mouth hurt when clenched? Yes    No

Does any part of your mouth hurt when clenched? Yes    No

have you had Braces    Oral surgery    Gum treatment    Root canal Do you grind or clench your teeth during the day or night? Yes    No

Do you smoke? Number per day Yes    No

Do you or does any family member have a problem with snoring? Yes    No

Have you ever experienced any growths or sore in your mouth? If so, where? Yes    No

Does any part of your mouth hurt when clenched? Yes    No

Does any part of your mouth hurt when clenched? Yes    No

Previous problems with dental treatment? Specify

Are you satisfied with the appearance of your teeth? Please Specify

Other Dental Concerns

Office policy: Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be necessary to charge for the time lost. Patient 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. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required and consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependants is mine and I will assume responsibility for fees associated with these services