Hamilton City Dental new patient
Hamilton City Dental
New Patient Forms
Hamilton City Dental New Patient Form
Date
PID#
Medical Alert
Yes
No
Registration Information
Patient is a
Adult
Child
Adult under Gaurdianship, name:
Adult under Gaurdianship, name:
Name
Name
First
First
Last
Last
Initial
Dr.
Mr.
Ms.
Mrs.
Miss.
Address: Street
Address 2: Street
City & Province
Postal Code
Reason for todays visit
Examination
Emergency
Other
Other
Is there a dental problem you would like treated immediately?
Preferred appt. time?
Home Phone
Cell Phone
Bus. Phone
Ext.
Employer
May we call you at work?
Yes
No
Email Adress
Prefers to be called:
Occupation:
Date Of Birth
Date Of Birth
Month
Month
Day
Day
Year
Year
Martial Status
Name Of Spouse
Are other family members patients at our office?
No
Yes, Name:
Yes, Name:
Whom may we thank for referring you
Family Physician
Phone
Medical Specialist
Phone
In case of emergency
Phone
Nearest relative not living with you
Phone
Dental History
Is there a dental problem you would like treated immediately?
No
Yes
Yes
Date of your last dental visit
Last dental cleaning
Last X-ray
1. Are you having regular dental visits
Yes
No
2. Have you ever had any of the following:
Periodontal Treatment (treatment of gums)?
Orthodontic Treatment (to straighten or realign teeth)?
A bite plate or any other appliance?
Your bite adjusted or teeth ground?
Oral Surgery (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints)?
3. How often do you brush your teeth?
Do you feel like you have bad breath?
Yes
No
4. Do you use dental floss
Yes
No
How often
5. Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?
Yes
No
6. Does food catch between your teeth?
Yes
No
7. Are any of your teeth sensitive to heat, cold, sweets or pressure?
Yes
No
8. Have you ever experienced any of the following jaw problems?
Popping/clicking in your jaw joints?
Pain in your jaw joints, around your ear, or side of your face?
Pain when teeth are clenched?
Pain or difficulty when chewing?
9. Do you have any of the following habits?
Clenching or grinding your teeth while awake or asleep?
Biting your cheeks or lips?
Mouth breathing while awake or asleep?
Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?
10. Do you have any emotional concerns about having dental treatment?
Yes
No
11. Are you unhappy with the appearance of your teeth?
Yes
No
What would you like to see changed?
12. Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or, do you have any o questions or concems?
Yes
Yes
No
Health History
1: Are you being treated for any medical condition at present or within the past year?
Yes, Please Explain
Yes, Please Explain
No
2. Has there been any changes in your general health in the past year?
Yes
No
3. When was your last visit to a Physician?
Last complete physical examination?
4. List any PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken (including birth control pills)
5. Have you ever had any adverse or unusual reaction to any medications or injections? (e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic (“dental freezing”)?
Yes, Please Explain
Yes, Please Explain
No
6. Have you ever been advised against taking any specific type of medication?
Yes
No
7. Do you have any allergies (e.g. hay fever, food allergies, latex/rubber or metal allergies)?
Yes
No
8. Have you ever fainted during dental or medical treatment?
Yes
No
9. Do you bleed excessively from a cut or injury, bruise easily or have any blood disorders?
Yes, Explain
Yes, Explain
No
10. Are you on cortisone or steroid therapy, or, are you on a diet pill therapy?.
Yes
No
11. Do you have any artificial joints (e.g. hip, knee)?
Yes
No
12. Have you ever been advised to take antibiotics before dental treatment?
Yes
No
13. Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic Fever?
Yes
No
14. Do you have, or have you ever had, any heart or blood pressure problems (heart or stroke)?
Yes, Please Explain
Yes, Please Explain
No
15. Do you have or have you ever had any chest pain, shortness of breath or any heart palpitation without exertion?
Yes
No
16. Are you presently suffering from any infectious diseases?
Yes
No
17. Do you have any condition that could affect your immune system (eg. arthritis, AIDS, HIV infection, lupus, inflammatory bowel disease, Crohn’s disease)?
Yes, Please Explain
Yes, Please Explain
No
18. Have you ever had any malignant disease, or are you presently undergoing any radiation treatment/chemotherapy?
Yes
No
19. Indicate which of the following you presently have, or ever had: (Please check all that apply)
Asthma
Bronchitis
Emphysema
Lung Disease
Epilepsy or Seizures
Hepatitis
Jaundice
Liver Disease
Tuberculosis
Diabetes
Kidney Disease
Thyroid Disease
Glandular Disorders
Organ Transplant/Medical Implant
Stomach/Intestinal Problems
Ulcers
20. Do you, or did you smoke?
Do you drink alcoholic beverages on a regular basis?
Use Recreational Drugs
21. WOMEN ONLY: Are you pregnant?
Yes
No
If pregnant, delivery date?
Are you breast feeding?
22. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?
Yes
No
23. Do you currently have, or ever had in the past, any disease, condition or problem not listed above?
Yes, Please Explain
Yes, Please Explain
No
24. Is there anything else about your health we should be made aware of, or do you wish to speak to the doctor privately about any problem or medical condition?
Yes, Please Explain
Yes, Please Explain
No
25. How Did You Hear About Our Office?
Notes:
General 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. Should there be any change in my health status in the future, 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, and I consent to the release of this information. 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.
Who is signing
Patient
Parent
Gaurdian
Name
Signature
Clear
Reviewed by treating dentist
Date
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