Hamilton City Dental new patient

Hamilton City Dental

New Patient Forms

Hamilton City Dental New Patient Form
Medical Alert

Registration Information

Patient is a
Name
Name
First
Last
Reason for todays visit
May we call you at work?
Date Of Birth
Date Of Birth
Month
Day
Year
Are other family members patients at our office?

Whom may we thank for referring you

Dental History

Is there a dental problem you would like treated immediately?
1. Are you having regular dental visits
2. Have you ever had any of the following:
Do you feel like you have bad breath?
4. Do you use dental floss
5. Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?
6. Does food catch between your teeth?
7. Are any of your teeth sensitive to heat, cold, sweets or pressure?
8. Have you ever experienced any of the following jaw problems?
9. Do you have any of the following habits?
10. Do you have any emotional concerns about having dental treatment?
11. Are you unhappy with the appearance of your teeth?
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?

Health History

1: Are you being treated for any medical condition at present or within the past year?
2. Has there been any changes in your general health in the past year?
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”)?
6. Have you ever been advised against taking any specific type of medication?
7. Do you have any allergies (e.g. hay fever, food allergies, latex/rubber or metal allergies)?
8. Have you ever fainted during dental or medical treatment?
9. Do you bleed excessively from a cut or injury, bruise easily or have any blood disorders?
10. Are you on cortisone or steroid therapy, or, are you on a diet pill therapy?.
11. Do you have any artificial joints (e.g. hip, knee)?
12. Have you ever been advised to take antibiotics before dental treatment?
13. Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic Fever?
14. Do you have, or have you ever had, any heart or blood pressure problems (heart or stroke)?
15. Do you have or have you ever had any chest pain, shortness of breath or any heart palpitation without exertion?
16. Are you presently suffering from any infectious diseases?
17. Do you have any condition that could affect your immune system (eg. arthritis, AIDS, HIV infection, lupus, inflammatory bowel disease, Crohn’s disease)?
18. Have you ever had any malignant disease, or are you presently undergoing any radiation treatment/chemotherapy?
19. Indicate which of the following you presently have, or ever had: (Please check all that apply)
21. WOMEN ONLY: Are you pregnant?
22. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?
23. Do you currently have, or ever had in the past, any disease, condition or problem not listed above?
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?

General Release

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