PATIENT HEALTH RECORD

PATIENT HEALTH RECORD

Your co-operation in filling out this questionnaire is essential in aiding us to perform the highest standard of dental care.All information is strictly confidential and will remain with this office.
Date

MonthDay Year
Date
Email*
example@example.com
Title:*

Dr.Mr.Mrs.Ms.
Name*

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:

Area Code Phone Number
Office Phone:

Area Code Phone Number
Mobile Phone:*

Area Code Phone Number
Date of Birth:*

MonthDay Year
Date
Sex:*

MaleFemale
Marital Status:
Occupation:
Employer:
Dental Insurance:

YesNo
Insurance Company Name:
Group/Policy #
Member I.D. #
Sec Insurance Co. Sec
Sec Co-Ins Policy Holder Name:
D.O.B.

MonthDay Year
Date
Sec Group/Policy #:
Sec Member I.D. #
Sec Insurance Employer:
Previous Dentist:
Whom may we thank for referring you?:
In Case of Emergency Notify: Name:
In Case of Emergency Notify: Phone:
CONFIDENTIAL MEDICAL HISTORY
Family Physician:
Phone #

Area Code Phone Number
Have you been under a physician’s care during the past 2 years?
Have you been treated in a hospital in the past 2 years?
Have you had major surgery?
Have you had cankers or cold sore on your lips, tongue, gums or body?
Are you now taking or have you taken any prescription drugs during the past year?
Do you smoke or chew tobacco products?

YesNo
For Women Only:
Are you taking hormones or birth control?*

YesNo
Are you breastfeeding or pregnant?*

YesNo
If pregnant, what is the expected delivery date?

MonthDay Year
Date
Are you allergic to: ( check all that apply)*

PenicillinCodeineLocal AnestheticsLatex
Do you have or have you had? (check boxes)

HIV + /AIDSNervous DisorderHerpesStrokeHigh Blood PressureLow Blood PressureThyroid DiseaseEpilepsyCancerPsychiatric CareVenereal DiseaseChestPainHeart MurmursDiabetesShortness of BreathSwollen AnklesHeart Trouble/AttackLiver disorderSinus ProblemsX-Ray TherapyHeart DiseaseHepatitisArthritisMalignant HyperthermiaFainting SpellsKidney disorderUlcersAbnormal Weight ChangeBlood DisordersGlaucomaArtificial Heart ValvesAllergiesDrug DependencyCongenital Heart LesionsPacemakerOrgan TransplantAnginaArtificial JointsChemotherapyJaundiceProlonged BleedingTuberculosisRadiation TherapyRheumatic FeverPolioProlonged CoughAsthma
Do you have or have you had any disease, condition or problem not listed above?
Confidential Dental History
When was your last dental visit?*
How often did you see your dentist?*
Are you having any dental problems that require immediate attention?*
Do any of the following cause tooth discomfort?

HotColdSweetsChewing
Do your gums bleed or are they sore while cleaning?*
Have you had periodontal treatment?*
When?
Do you clench or grind your teeth?*
Do your jaws ever feel tired or ache?*
Click or pop?
Can you chew on both sides of your mouth?*
Comfortably?
Do you have frequent headaches?*
Earaches?
Do you usually have many cavities?*
How do you feel about the appearance of your smile?*
Have you ever had any cosmetic dentistry done to improve your appearance?*

YesNo
If yes, are you pleased with the result?

YesNo
Please Comment:
Do you currently experience:*

Loose TeethBad BreathStained TeethUnsatisfactory DenturesNeck PainGaggingMissing TeethUnexplained NosebleedSpaced or Crooked TeethDiscoloured Dark TeethNone of the above
Are you nervous during dental treatment?*

NoYesModeratelyVery Tense
Please add anything you feel is important:
Office Policy

1. Payments: Payment for service is expected at the end of each visit. Certain circumstances require special consideration.
Please discuss these with your dentist.

2. Appointments: In order to treat you effectively, we will reserve an appointment time solely for you. We require your co-operation
in keeping these appointments. If you cannot keep your appointment time, we require 48 hours notice. Otherwise, a fee will be
assessed.

Consent for Treatment

This is to certify that I, the undersigned, have read the foregoing and consent to the performing of the dental procedures agreed to be
necessary or advisable. I will assume responsibility for fees associated with those procedures.
Patient/Parent/Guardian Signature:*

Clear
Date

MonthDay Year
Date
Should be Empty:

PATIENT HEALTH RECORD

CONFIDENTIAL MEDICAL HISTORY

For Women Only:

Confidential Dental History

Office Policy

Consent for Treatment