Patient Information - Adult

Your cooperation in filling out the data on the confidential questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain in this office.   First name: Last name: Middle name: Date of Birth : Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Sex : Male Female   Marital Status: married single divorced     Address : Street : Town : Province : -Please Choose One- Alberta British Columbia Manitoba New Brunswick Newfoundland North West Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code :   Contact Info : Home Phone : Work Phone : Cell Phone : Email Address :   In Case of Emergency, please notify : Name : Relationship : Address : Telephone :         Whom may we thank for referring you?

Insurance Information

Name of person responsible for account :
Address :	Street : Town : Province : -Please Choose One- Alberta British Columbia Manitoba New Brunswick Newfoundland North West Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code :
Occupation :	Business Phone : Employer :
Dental Ins. :	Yes No Name of Company :
Ins. Policy # :	Employee I.D. #
Dental Insurance Subscriber :
	Name : Date of Birth : Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Yes No	I authorize release to my insurance company plan administrator the information contained in claims submitted electronically.

confidential Medical history

1. Are you presently, or within the past year, under treatment for a medical condition ?

Yes No - Reason :

2. Family Physician: - Phone:

3. Are you presently taking any pills, drugs or medication?

Yes No -Details :

4. Have you taken any prolonged medication in the past? Prescription or non-prescription?

Yes No - Details :

5. Have you heart disease, murmur, a congenital heart defect or an artificial heart valve?

Yes No - Details :

6. Have you had abnormal bleeding?

Yes No - Details :

7. Have you any allergies (food, latex, rubber) ?

Yes No - Details :

8. Have you allergies to any drugs or medication? (ie. Codeine/Penicillin)

Yes No - Details :

9. Have you every been hospitalized and was surgery performed?

Yes No - Details :

10. Do you have, or have you had? (please check)

High Blood Pressure Diabetes Asthma Kidney Trouble Low Blood Pressure Liver Trouble Rheumatic Fever Shortness of Breath Nervous Problems Hepatitis Sinus Problems Radiation Treatment Thyroid Problems Blood Disorders Stroke Psychiatric Care Are you Pregnant? H.I.V. Tuberculosis Venereal Disease Heart Trouble Herpes Ulcer Scarlet Fever Chest Pain Cancer Fainting Spells Epilepsy Anemia Arthritis

11. Are you currently in good health? Yes No

12. Is there anything else you think you should tell me?

Confidential Dental Information

1. Previous dentist: Phone:

2. Are you having any discomfort at this time? Yes No - Details :

3. How long since your last dental visit?

4. What was done at that time?

5. Do your gums feel tender or swollen? Yes No - Details :

6. Have you ever been given local anesthetic?(freezing) Yes No - Details :

7. Any complications with # 6? Yes No - Details :

8. Are you aware of any lump or swelling in your mouth? Yes No - Details :

9. Are you satisfied with the appearance of your teeth? Yes No - Details :

10. Are you tense during dental visits? Yes No - Details :

11. Please list any other conditions that you have not mentioned above.

12. Do you currently experience: (please check)

loose teeth neck pain spaced or crooked teeth headache sore gums unexplained nosebleed bad breath gagging ear ache missing teeth unsatisfactory dentures   sensitive teeth bleeding gums popping or clicking in the jaw joints

If Yes, describe :

Additional Information

Describe in your own words what you would like done with your teeth:

CONSENT FOR TREATMENT

This certifies that I the undersigned, consents to the agreed upon, necessary, or advisable dental procedures.I will assume full responsibility for the fees associated with these procedures.
Signature :
Date :