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

New Patient Form Print 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 collection, using and disclosing this information responsibly.

REGISTRATION INFORMATION –This information will enable us to maintain communication with you

The patient is an*:    Adult.    Child.    Adult under guardianship    Name of Guardian

Name*

*Mr.    Mrs.    Miss.    Mrs.    Ms.    Dr.

Prefers to be called
Language Preference*

Address*

Home Phone*
Bus. Phone
Cellphone*

Email*
Employer
May we call you at work?

Date of Birth:*
Age*
Sex*
Marital Status*
Name of Spouse

Preferred appointment time*
Whom may we thank for referring you?


Are other family members patients at our office? Yes
Name

MEDICAL PRIORITY – This information will enable us to make any essential contacts.

Family Physician *
Phone *

Medical Specialist (if presently under care)
Phone

In Case of emergency, please contact *
Phone *

Nearest relative not living with you *
Phone*


Reason for today’s visit? *   Examination    Emergency
Other

Is there a dental problem you would like treated immediately? *

FINANCIAL INFORMATION – This information is necessary to process invoices and apply payments.


Person responsible for account:*    Self    Spouse
Other

Name *
Phone*

Address*
Employee*

Method of payment *    CASH    CHEQUE    CREDIT CARD    OTHER

PRIMARY DENTAL INSURANCE

Subscriber’s name *
DOB *

Insurance Comp *

Policy holder *
Cert.num

SECONDARY DENTAL INSURANCE

Subscriber’s name
DOB

Insurance Comp

Policy holder
Cert.num



I authorize release to my benefits plan administrator information contained in claims submitted electronically. Also, I hereby assign my benefits, payable from claims submitted electronically, to My Smile Dentistry on King and authorize payment directly to them.This authorization shall continue in effect until the undersigned revokes the same.

DENTAL HISTORY – Please YES or NO to each question. If unsure of a question, please consult with the dentist.


1. Is there a dental problemyou would like treated immediately?*    Yes    No
If Yes, please explain

2. When was your last dental visit? *
Last dental Cleaning? *
Last x-rays? *

3. Have you been seeing dentist regularly?*    Yes    No

4. Have you ever had any of the following?
A. Periodontal treatment (treatment of gums)*    Yes    No
B. Orthodontic treatment (to straighten teeth)*    Yes    No
C. A bite plane or any other appliance*    Yes    No
D. Your bite adjusted or teeth ground*    Yes    No
E. Oral surgery (surgery or implant in or about the mouth or jaw joint)*    Yes    No
If you answered yes to last question who performed the surgery and when?

5. Are you being followed up by a dental specialist.* Yes    No
If yes, please explain?
6. Are there any growths or sore spots in your mouth?*    Yes    No
7. Do your gums bleed when brushing or eating or do you suffer from pain/swelling of your gums*    Yes    No
8. Have you noticed any loose teeth, or, have any of your teeth shifted*    Yes    No
9. Does food catch between your teeth?*    Yes    No
10. Are any of your teeth sensitive to heat, cold, sweets or pressure?*    Yes    No
11. Have you been advised to take antibioticsbefore dental appointment?*    Yes    No
12. How often do you brush your teeth?*

Do you feel that you have bad breath?*    Yes    No
13. Have you ever experienced any of the following jaw problems:
Popping/clicking in your jaw joints?*    Yes    No
Pain in your jaw joints, around your ear, or side of your face?*    Yes    No
Difficulty in opening or closing?*    Yes    No
Pain when teeth are clenched?*    Yes    No


14. Do you have any of the following habits?
Clenching or grinding your teeth while awake or asleep?*    Yes    No
Biting your cheeks or lips?*   Yes    No
Mouth breathing while awakeor asleep?*    Yes    No
Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?*    Yes    No


15. Do you have any emotional concerns about having dental treatment?*    Yes    No
16. Have you ever had any upsetting experience in dental office, or any complications during or after dental treatment,Or, do you have any questions or concerns?*    Yes    No
If yes, please explain.
17. Are you unhappy with the appearance of your teeth?*
   Yes    No
If yes, what would you like to see changed?
18. Do you feel your dental health influences your overall health?*    Yes    No
19. On a scale of 1 to 10, (10 being highest), how important is it for you to keep your natural teeth?*
GENERAL RELEASE (Please sign after completing medical questionnaire)

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 ofthe 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.

Please YES or NO to each question. If unsure of a question, please consult with the dentist.

1. Are you being treated for any medical condition at present or within the past two years?*    Yes    No
If yes, please explain.
2. Have you been hospitalizedfor any illnesses or operations in the past two years?   * Yes    No
If yes, please explain.
3. Has there been any change in your general health in the past year?   * Yes    No
If yes, please explain.
4. When was your last visit to a Physician?*
Last complete physical examination?*
5. Have you recently, or are you presently, taking any prescription or non-prescriptiondrugs incl.herbal remedies*    Yes    No
If yes, please list medications
6. Have you ever had a peculiar or adverse reaction to any medications or injections?*    Yes    No
Penicillin, Clindamycin, Aspirin, Local Anesthetic, Nitrous Oxide or any other medicine:
7. Have you ever been advised against taking any specific type of medication?*    Yes    No
If yes, please explain
8. Do you have any of the following? (Please circle) Asthma, Hay Fever, Food Allergies, Metal or Latex Allergies, Skinrashes, Hives or any other Allergic reactions.*
9. Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?*    Yes    No
If yes, please explain
10. Is there a family history of Diabetes, Cancer or Heart Disease?*    Yes    No
11. Do you have have or have you ever had anyheart or blood pressure problems?*    Yes    No
12. Do you have or ever had a replacement/repair of a heart valve, an infection of the heart (i.e. infective endocarditis),a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*    Yes    No
13. Do you have prosthetic or artificial joint?*    Yes    No
14. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection,Radiotherapy, chemotherapy)?*    Yes    No
15. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?*    Yes    No
16. Do your ankles, feet or hands swell?*    Yes    No
17. Has your weight, appetite or energy level changed dramatically recently?*    Yes    No
18. Do you follow a special diet, or are you on diet pill therapy?*    Yes    No
19. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?*    Yes    No
20. Have you or anyone in your family tested HIV positive or have Hepatitis A B or C?*    Yes    No
21. Do you have FREQUENT SEVERE headaches, ear aches, ear/throat infections?*    Yes    No
22. Have you had any injury or surgery to your face or jaws?*    Yes    No
23. Do you wear eyeglasses or contact lenses?*    Yes    No
24. Do you have any hearing difficulties?*    Yes    No
25. Do you smoke orchew any forms of tobacco? Or, are you wearing a transdermal nicotine patch?*    Yes    No
26. Are you alcohol and/or drug dependent? And, have you received treatment?*    Yes    No
27. PLEASE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD:*
AIDS
Anemia
Angina Pectoris/ Chest Pain
Arthritis/ Rheumatism
Artificial Hip(replacement)
Artificial Knee(replacement)
Blood disorders
Bronchitis
Cancer
Congenital heart lesions
Cortisone/Steroid therapy
Crohn’s disease
Diabetes
Drug/ cannabis use
Emphysema
Epilepsy or seizures
Fainting or dizzy spells
Glandular disorders
Glaucoma
Head/Neck injuries
Heart Attack/Disease
Heart Murmur
Heart Pacemaker
Heart rhythm disorder
Heart Surgery
Hepatitis A B C
Herpes
High Blood Pressure
Hodgkin’s Disease
Hypoglycemia
Hyperglycemia
Hypertension
Inflammatory bowel disease
Kidney Disease
Liver disease
Low Blood Pressure
Lung Disease
Lupus
Malignant Hyperthermia
Mental/Nervous disorder
Mitral valve prolapse
Organ transplant/medical implant
Osteoporosis medications
Radiation/chemotherapy
Scarlet/ Rheumatic fever
Sickle Cell Disease
Sinus Trouble
Stomach/intestinal problem/ulcer
Stroke
Thyroid disease
Tuberculosis
Venereal Disease


28. Has the CHILD PATIENT recently had any of the following?* (indicate approximate date).
Measles    Strep Throat    Mumps    Tonsilitis    Chicken Pox   

29. Do you currently have, or have you had in the past, any disease, condition or problem not listed?*    Yes    No

30. Is there anything else about your health we should be made aware of?*    Yes    No
31. Do you wish to speak privately to the Doctor about any problem or medical condition?*    Yes    No

32. WOMEN ONLY:
Are you pregnant or suspect you may be?
Are you breastfeeding?
Are you taking any birth contol pills?
Women over 50: Are you aware of your bone mineral density?