2023 NP OAT Consult

PERSONAL INFORMATION
Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

DayMonthYear
Date
Gender
Referred By? (ie: Google, Walk By, Friend or Family Member Name)
How did you hear about us?*

Google SearchGoogle ReviewWalk byLive in AreaFamily/Friend ReferralDentist/Specialist ReferralOther
Please provide the name of the person or office who referred you.*
Emergency contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Please enter a valid phone number.
Dental Insurance Information (if applicable): Insurance Carrier Name
Dental Insurance Information: Subscriber Name
Dental Insurance Information: Subscriber Date of Birth

MonthDayYear
Date
Dental Insurance Information: Relation to Patient
Dental Insurance Information: Policy / Plan/ Group #
Dental Insurance Information: Certificate or ID #
Alberta Health Care #*
Payment Options
Patients are responsible for payment of all dental services. All dental services are charged directly to the patient when treatment is rendered. For your convenience, we accept Debit, Visa & MasterCard. For patients with dental insurance coverage, we will assist submitting claim forms for your direct reimbursement. Note: it is the responsibility of the patient/insurance subscriber to understand the benefits & limitations of their dental coverage plan. Please initial indicating you have read the above.*
Personal Information Disclosure Agreement
We are committed to protecting the privacy of our patients’ personal information & to utilizing all personal information in a responsible and professional manner. Patient personal information is collected and used for the purpose of updating personal profiles, invoicing, processing insurance claims, sending reminders and sending information to patients about out dental practice. Patient medical information is collected and used for the purpose of diagnosing dental conditions, treatment planning and providing dental treatment. Please initial indicating you have read the above.*
Cancellation Policy
Glamorgan Dental requires 2 business days notice to cancel or reschedule a reserved appointment. A $75 fee will apply to changes to reserved appointments with insufficient notice. Please initial indicating you have read the above.*
Mission Statement: Your Smile + Our Work = Together It’s Our Commitment for Better Oral Health! Our goal is to treat our patients based on their needs and wants for optimal dental and overall health. Each team member plays an important part in our success. Our satisfaction comes from patients who appreciate our efforts, care about their health and well-being and take responsibility for wanting the best level of care for themselves, their family and their friends.
INFORMED CONSENT
I, the undersigned, do hereby authorize and consent to the administration of all dental procedures deemed necessary or advisable for myself, or my child, by the attending dentist, including but not limited to, the use of local anesthetics or other prescribed medications. I shall assume the responsibility for payment of all fees associated with treatment procedures provided. I consent to collection, use and disclosure of my personal information for the purposes outlined in the personal information consent agreement. I have reviewed the foregoing information and consent. I have had the opportunity to ask questions and understand the above consent.
Patient Signature*

Clear
Date*

MonthDayYear
Date
DENTAL HISTORY
How would you rate the condition of your mouth?*

GoodFairPoor
Name of current or previous dentist.*
Name of Clinic and/or address:*
Date of most recent exam.*
Date of most recent xrays.*
Date of most recent dental treatment.*
Date of most recent cleaning.*
I routinely see my dentist every:*

3 months4 months6 months12 monthsNot routinely
What is your immediate dental concern?*
Please select if any of the below apply. If nothing applies, please select NONE.*

Are you fearful of dental treatment?Have you had an unfavorable dental experience?Have you ever had complications from past dental treatment?Have you every had trouble getting numb or reactions to local anesthetic?Do you often feel tired, fatigued, have a hard time concentrating?Do you snore?Do you have sleep apnea?Have you ever had a sleep test or study?Is there anything about the appearance of your teeth that you would like to change?Have you ever whitened (bleached) your teeth?Are you self-conscious about yoru teeth?Have you been disappointed with the appearance of previous dental work?Do you have problems chewing gum?Do you have problems chewing bagels or other hard foods?Have your teeth changed in the last 5years, become shorter, thinner or worn?Are your teeth crowding, developing spaces or catching food?Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?Did you ever have braces or had your bite adjusted?Do you have any problems with sleep or wake up with an awareness of your teeth?Have you ever had any teeth removed?Do you have dentures or partial dentures?Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping?Do you have tension headaches or sore teeth?Do you wear or have you ever worn a bite appliance?Have you had any cavities withing the past 3 years?Do you have a dry mouth?Do you regularly breathe through your mouth?Are any teeth sensitive to hot, cold, biting or sweets?Have you ever had a tooth ache, cracked filling, broken, chipped or cracked tooth?Do you avoid brushing any part of your mouth?Do you fell or notice any holes(ie: pitting) in your teeth?Do you bite your nails or chew on objects with your front teeth?NONE
Is your sugar intake?*

LowModerateHigh
Where does your sugar come from?
Please select if any of the below apply.

Have you every been diagnosed or treated for periodontal (gum) disease?Have you ever experienced gum recession?Is there anyone with a history of periodontal disease in your family?Do your gums bleed when brushing, flossing or eating?Have you ever noticed an unpleasant taste or odor in your mouth?Have you experienced a burning sensation in yoru mouth>
How often do you brush your teeth?
How often do you brush your tongue?
How often do you floss?
Do you use any of the following?

Electronic toothbrushFloss aidsMouth rinseSpecialty toothpaste
MEDICAL HISTORY
Name

First NameLast Name
Preferred Name
Do you currently have a Family Physician?*

YesNo
Family Physician*

First NameLast Name
Clinic Name of Physician*
Date of recent medical physical examination
Clinic address:
How would you rate your general health?*

GoodFairPoor
Please select if any of the below apply. If nothing applies, please select NONE.*

Hospitalization of illness or injury.Allergy to latexAllergy to aspirin, ibuprofen, acetaminophenAllergy to penicillinAllergy to erythromycinAllergy to tetracyclineAllergy to codeineAllergy to local anestheticAllergy to fluorideAllergy to metals (ie: gold, stainless steel)NONEOther
Please select if any of the below apply. If nothing applies, please select NONE.*

AsthmaAnemia or blood disorderArtificial joints or heart valvesArthritisAny lumps or swelling in the mouthAnxiety/DepressionBreathing or sleeping problemsChemotherapyDiabetesDizziness or faintingDigestive disorders (ie: gastric reflux)EmphysemaEpilepsy/ convulsions or seizuresGlaucomaRheumatic fever or scarlet feverHeart murmurHeart problems/conditionsHead or neck injuriesHepatitis or JaundiceHigh blood pressureHistory of strokeHigh cholesterolHIV/AIDSHives, skin rash or hay feverHormonal deficiencyKidney diseaseLiver diseaseLow blood pressureMad cow disease, Gerstmann-Straussler-Scheinker disease or fatal familial insomniaNeurological problems (ie: memory loss)PacemakerPsychiatric treatmentProlonged bleeding after cutRadiation TherapyShortness of breathStomach problems (ie: ulcer)Thyroid or parathyroid diseaseTuberculosisViral infections & cold soresVenereal dieseaseTumor or abnormal growthAre you aware of changes in your general health?Are you on medication for osteporosis/ osteopenia?Are you subject to frequent headaches?Are you often exhausted or fatigued?Are you a smoker or smoked previously?Are you experiencing any lack of muscle coordination, dementia, twitches or tremors?Females-Are you taking any contraceptives?Females-Are you pregnant?MEN- Prostate disorders?Are you being treated for any other illness?NONEOther
Describe any current medical treatment, surgeries or other treatment that you are currently undergoing or will be undergoing:
Please list ALL medications, supplements and/or vitamins taken within the last 2 years.
Signature*

Clear
Date*

MonthDayYear
Date
Sleep History
Name

First NameLast Name
Chief Complaints

What are the reasons that you are seeking treatment? Please number the concerns in order, with 1 being he most important.
Snoring*
Daytime drowsiness or fatigue*
I have been told that I stop breathing when sleeping*
Difficulty falling or staying asleep*
Feeling un -refreshed in the morning*
Morning headaches*
Difficulty in concentrating or forgetfulness*
Other, please specify
Date

MonthDayYear
Date
Have you attempted a CPAP?*

YesYes, but I could not tolerate itNo
If you have attempted a CPAP but could not tolerate it, please indicate why (check all that apply):*

Unable to get the mask to fit properlyDiscomfort with the straps and head gearNoiseCPAP does not seem to be effectiveFeeling of claustrophobiaKept removing it at nightOther
Other therapy attempts:

Weight lossPositional therapySurgeriesOther
If surgeries, please indicate:*
Sleep History
What time are you going to bed?*
What time do you wake up?*
Please select ALL that applies. If nothing applies, please select NONE APPLY:*

Do you notice an unsettled or restless sensation in your legs at night?Have you been told that you jerk or twitch your legs while sleeping?Do you snore?Do you have a bed partner?Does your bed partner disturb your sleep ?Do you have any light in your room at night?NONE APPLY
Do you notice an unsettled or restless sensation in your legs at night?*

YesNo
Have you been told that you jerk or twitch your legs while sleeping?*

YesNo
Do you snore?*

YesNo
Do you have a bed partner?*

YesNo
Does your bed partner disturb your sleep?*

YesNo
Do you have any light in your room at night?*

YesNo
If yes, what is the source?*
Do you drink caffeinated beverages?*

YesNo
Do you drink caffeinated beverages?*

YesNo
If yes, how much?*
When do you consume caffeinated beverages?*
Has your weight changed in the last year?*

YesNo
Has your weight changed much in the last year?*

YesNo
If yes, by how much?*
Do you use electronic devices, phones or watch television within 1 hour before bed?*

YesNo
Do you use electronics or watch television within 1 hour before bed? (i.e., computer, iPads, phones, etc)*

YesNo
Are there any other disturbances to your sleep?(ie: allergies, pets, etc.)*
How many times do you wake during the night?*
What causes you to wake?*
How long does it take for you to fall back asleep?*
Do you sleep on your side, back or stomach?*
How many alcoholic beverages do you consume daily?*
How many alcholic beverages do you consume weekly?*
How many alcoholic beverages do you consume monthly?*
How often do you exercise? (weekly, monthly, never)*
Do you excercise?*

Yes, weeklyYes, monthlyNever
How many times?
What time is your last meal?*
Should be Empty:

PERSONAL INFORMATION

Payment Options

Personal Information Disclosure Agreement

Cancellation Policy

INFORMED CONSENT

DENTAL HISTORY

MEDICAL HISTORY

Sleep History

Chief Complaints

Sleep History