zNew Patient Chart
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Person responsible for this account:
Self
Spouse
Parent
Legal Guardian
Other
MCP Number
II. Medical Information (Confidential)
Are you currently under the care of a physician?
Yes
No
If so, please speify
Have you ever had serious illness requiring hospitalization or extensive medical care?
Yes
No
Please Specify
Do you use any prescription or non prescription drugs regularly (including herbals/vitamins)?
Yes
No
Please list
Do you have any allergies to
Aspirin
Codeine
Latex
Antibiotics
Sulfa Drugs
Anesthetics/Topical
New Option
Sleeping Pills
Other Medications
If you have any other allergies not listed above, please list
Have you been warned against taking any drug or medication?
Yes
No
Please specify
Do you bruise easily or bleed abnormally?
Yes
No
Do you require any pre-mediation (antibiotics) for dental treatment?
Yes
No
Have you ever had any organ transplants or medical implants?
Yes
No
Do you ever experience shortness of breath or chest pain when taking a walk or climbing stairs?
Yes
No
Do you have AIDS or have tested positive for H.I.V?
Yes
No
Do you have any of the following? Please check any that apply.
Heart murmur/mitral valve prolapse
Epilepsy or Seizures
Herpes
Liver Disease
Sinus Trouble
Stomach/intestinal problems
Drug/alcohol dependency
Venereal Disease
Heart Attack
Stroke
Cold Sores
Joint Replacement (hip/knee)
Lung Disease ( Asthma)
Kidney Problems
Mental Health Disorders
Thyroid Disease
High/Low Blood Pressure
Emphysema
Glaucoma
Low Blood Pressure
Arthritis or Rheumatism
Tuberculosis
Hyper(hypo) Glycemia
Scarlet or Rheumatic Fever
Hepatitis A,B,C
Diabetes
Cortisone/Steroid Therapy
Have you had any injury, surgery or radiation therapy to your face, jaw or neck?
Yes
No
Does your family have a history of head, neck and/or oral cancer?
Yes
No
Do you smoke?
Yes
No
If so, how long have you been smoking?
How much do you smoke in one day?
Do you have any diseases, conditions or problem that you think the doctor should know about?
Yes
No
If so, specify
Women Only
Are you pregnant or suspect you might be?
Yes
No
If so, how far along are you (weeks)?
Are you nursing?
Yes
No
Are you taking Birth Control?
Yes
No
III. Dental History
Reason for visiting our office
Exam
Cleaning
Emergency
Other
If other, specify
Are you presently having dental pain?
Yes
No
If yes, specify
How frequently do you see your dentist?
6 month
Yearly
Other
If other, specify
Last dental visit
Last Cleaning
How often do you brush your teeth?
Do your gums bleed easily?
Yes
No
Are your teeth sensitive to any of the following?
Hot
Cold
Biting
Sweets
Do you feel you have bad breath at times?
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
Have you had any of the following?
Braces
Oral Surgery
Gum Treatment
Root Canal
Have you ever experienced any growths or sore spots in your mouth?
Yes
No
If so, where?
Are you dissatisfied with the appearance of your teeth?
Yes
No
If you could, what features of your smile would you like to change?
Insurance companies now only allow for 'functionally acceptable work', whereas, in the past their coverage was for 'quality work'. It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. What is important to you? (check one)
The highest quality dentistry available
The most economical treatment plan
Dentistry limited to insurance coverage
A combination of the above, please explain
Informed Consent
PRIVACY ACT NOTIFICATION: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.
OFFICE POLICY: Your appointment time will be reserved for you. If you are unable to keep your appointment, we will require 1 business days notice, otherwise it may be necessary to charge for the time lost. Patients not showing for confirmed appointments may be charged accordingly.
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 I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.
