PERSONAL INFORMATION: PATIENT   Salutation Dr. Mr. Mrs. Miss Ms.   Last Name First Name Home Address City Prov. Postal Code DOB Home Ph. Bus. Ph. Ext. Whom may we thank for referring you to our office?     IF PATIENT IS A CHILD:   Father's Name: Father's Address: City: Father's Home Ph.: Father's Bus. Ph.: Ext.: Mother's Name: Mother's Address: City: Mother's Home Ph.: Mother's Bus. Ph.: Ext.:   PERSON TO CONTACT IN CASE OF EMERGENCY       Name: Home Ph.: Bus. Ph.: Address: City: Prov.: P.C.:     ACCOUNT INFORMATION   PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT SALUTATION Dr. Mr. Mrs. Miss Ms. Name   Occupation: Employer:   FINANCIAL RESPONSIBILITY   I UNDERSTAND THAT I AM RESPONSIBLE FOR FEES ASSOCIATED WITH TREATMENT PERFORMED INCUDING THOSE NOT COVERED BY MY DENTAL PLAN, IF ANY. PAYMENT IS DUE ON DAY OF SERVICE UNLESS OTHER ARRANGEMENTS AHVE BEEN MADE.   PATIENT'S (PARENT'S) SIGNATURE: DATE;   DENTAL HISTORY: To help us understand past dentistry, tell us about your experiences:   1. LAST VISIT: 2. LAST HYGIENE: 3. RADIOGRAPHS:   4. HAVE YOU EXPERIENCED: Orthodontics Periodontal (Gum) Treatment Extractions Root Canal Treatment Crowns Bridges Veneers Implants Dentures   5. DO YOU SUFFER FROM HEADACHES? YES NO 6. ARE YOU AWARE IF YOU GRIND OR CLENCH YOUR TEETH? YES NO 7. HAVE YOU NOTICED ANY TEETH BECOMING LOOSE? YES NO 8. DO YOU HAVE ANY TEETH WITH TEMPERATURE SENSITIVITY? YES NO 9. DO YOU GET FOOD CAUGHT BETWEEN TEETH? YES NO 10. IS THERE OFTEN BLEEDING WHEN YOU FOLSS OR BRUSH? YES NO 11. WHAT IS YOUR PRIMARY CONCERN FOR "TODAY'S" VISIT?     SOME MEDICATIONS AND HEALTH CONDITIONS CAN AFFECT ORAL HEALTH AND COMPLICATE DENTISTRY. A MEDICAL HISTORY IS VERY IMPORTANT. 1. ARE YOU GENERALLY IN GOOD HEALTH NOW? YES NO 2. WHEN WAS YOUR LAST MEDICAL EXAMINATION YES NO 3. PLEASE LIST ANY MEDICATIONS YOU TAKE ON A REGULAR BASIS, INCLUDING NON-PRESCRIPTION. (NAME AND DOSAGE) 4. (WOMEN) HAVE YOU REASON TO BELIEVE YOU ARE PREGNANT? YES NO 5. DO YOU HAVE ALLERGIES TO MEDICATION OR ANAESTHETIC THAT YOU ARE AWARE OF? YES /NO. PLEASE EXPLAIN 6. HAVE YOU HAD TO TAKE ANTIBIOTICS PRIOR TO ANY DENTAL TREATMENT? PLEASE EXPLAIN. 7. HAVE YOU HAD HEART SURGERY INVOLVING THE HEART VALVES OR PACEMAKER? YES NO 8. DO YOU HAVE A HEART MURMUR? YES NO 9. HAVE YOU HAD RHEUMATIC FEVER? YES NO 10. DO YOU HIGH OR LOW BLOOD PRESSURE? NO HIGH LOW 11. HAVE YOU HAD A STROKE? YES NO 12. DO YOU HAVE DIABETES? IF SO, IS IT CONTROLLED BY DIET OR MEDICATION? NO DIET MEDICATION 13. DO YOU SUFFER FROM EXCESSIVE THIRST / URINATION OR FREQUENT DRY-MOUTH? YES NO 14. DO YOU HAVE EPILEPSY? YES NO 15. DO YOU HAVE DIFFICULTIES WITH CLOTTING? YES NO 16. DO YOU HAVE RESPIRATORY CONCERNS SUCH AS ASTHMA? VENTILATOR INHALER TB 17. DO YO USE ANY TOBACCO PRODUCTS? YES NO 18. HAVE YOU HAD SURGERY FOR TUMORS, TRANSPLANTS OR JOINT REPLACEMENTS? YES NO 19. DO YOU HAVE CHRONIC COLD SORES OR CANKER SORES? YES NO 20. HAVE YOU HAD HEPATITIS OR HIV? YES NO 21. IS THERE ANYTHING ELSE YOU FEEL WE NEED TO KNOW ABOUT YOUR MEDICAL HEALTH THAT MAY AFFECT YOUR TREATMENT?   PHYSICIAN'S NAME: PHONE: PHARMACY NAME: PHONE:   WHAT IS MOST IMPORTANT TO YO ABOUT YOUR DENTAL HEALTH AND WHAT DO YOU VALULE MOST ABOUT YOUR TEETH? (IN ORDER OF PRIORITY):   AESTHETICS COMFORT FUNCTION LONGEVITY CONSENT FOR TREATMENT   I consent to the performing of dental procedures agreed to be necessary of advisable. I consent to the collection, use, retention and disclosure of personal information as is required for my own and dependants dental care. PATIENT'S (PARENT'S) SIGNATURE DATE: Security Code. Please enter the numbers/letters you see into the box. *