New Patient Form DAP

NEW PATIENT FORM

Welcome to our practice. Please fill out this form to help us better serve you.
Name

First NameLast Name
Preferred Title

MrMrsMissMsDrProf
Gender

MaleFemaleOther
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number
Mobile

Area CodePhone Number
Work Number

Area CodePhone Number
Email
example@example.com
Referred by

First NameLast Name
School (if student)
School year level
Ethnicity
NHI Number
Occupation
Medical History
Doctor/GP
Doctor/GP address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor/GP phone number

Area CodePhone Number
Have you ever had any of the following?

Heart MurmurIrregular heart beatRheumatic feverHeart AttackOpen heart surgeryArtificial heart valveAngina/Chest painHigh blood pressureCancerRadiotherapy for cancer treatmentChemotherapy for cancer treatmentStrokeNeurological problemsArthritisFaintingEpilepsyHay FeverSinus ProblemsAsthmaReflux/HeartburnChest/lung diseaseDiabetesKidney problemsGastric problemsOsteoporosis/OsteopeniaAutoimmune diseaseAnxietyDepressionHyperthyroidismHypothyroidismGenetic syndromeOrgan transplantBlood disordersOther
If you had any of above please tell us when you were diagnosed, treatments received and the results of the treatment(s).
Do you have any other medical conditions/problems that were not listed above? If yes, please give us more information on it.
Are you taking any medicines, tablets, pills or drugs? If yes please list them.
Have you ever had any allergies to medicines or other substances (such as latex)? If yes, please list them.
Are you a smoker?

NoYes
How many years have you smoked?
How many a day?
Do you have an artificial prosthetic joint?

NoYes
If yes, please state when and what prothesis was placed:
Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time?

NoYes
Please explain what procedure was done and the kind of treatment you received.
Have you ever had contact with:

HIV virusHepatitis B virusHepatitis C virus
Please give us some more information on it.
Have you ever had an unfavorable reaction to a local anaesthetic

NoYes
Please give us more information on it.
Woman: Are you pregnant now or trying to get pregnant?

NoYes
Please let us know your due date, or if you don't know, how many weeks pregnant you are.
Are there any other medical/health matters you would like to discuss with your dentist?

NoYes
Please let us know what they are.
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
COVID SCREENING
Do you have a confirmed diagnosis of COVID-19?

NoYes
Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID-19?

NoYes
Have you, or anyone living with you returned from overseas in the last 14 days?

NoYes
Do you, or anyone living with you have the following symptoms (Please tick all symptoms that apply).

Sore throatCoughShortness of breathHigh Temperature (38°C)Runny nose, sneezing, post-nasal drip
Oral Hygiene Habits
How many times a day you normally brush your teeth?

Not brushing dailyOnce a dayTwice or more a day
Brushing at least twice a day is fundamental for a healthy and clean mouth. Please tell us why you are not brushing your teeth at least twice a day.

Not enough timeIt is painfulGums bleed when I do itDont think it is important enoughOther
What kind of toothbrush you use?

Manual brushElectric toothbrush
Is your toothbrush:

SoftMediumHardDon't know
What kind of toothpaste do you use regularly?

With FluorideWithout Fluoride ("natural")For sensitive teethWhiteningDon't knowOther
Do you floss or clean in between your teeth daily?

YesNo
Cleaning in between your teeth is fundamental for a healthy and clean mouth. Please let us know why you are not flossing daily.

Too difficultIt is painfulGums bleed when I do itDon't think it is important enoughNot enough time for itOther
Dental Information
What are your main concerns regarding your mouth and dental care?
Could you please let us know what kinds of dental treatment you have received in the past? For example, braces, root canal treatment, fillings, cleans, extractions, crowns, etc.
Do you feel anxious when visiting the dentist?

NoYes
Please give us more information about it. For example, what is that you dislike and why.
Would you be interested in any form of sedation to help you through the treatment?

NoYes
Do you have any problems with your jaw joint? For example, noises, locks or pain.

NoYes
Please give us more information on it.
Are you interested in Botox or dermal fillers for concerns about wrinkles, expression lines, your lips or general appearance of your face?

NoYes
Please give us more information on it.
Are you happy with your smile and the colour/shape of your teeth?

NoYes
What would you like to change?
Are you concerned about the alignment/position of your teeth?

NoYes
Please give us more information on that.
Are you concerned about any missing teeth or gaps?

NoYes
Please give us more information on it.
Do your gums ever bleed or hurt?

NoYes
Please give us more information on it.
Have you ever noticed bad breath or are you concerned about it?

NoYes
Please give us more information on it.
Have you ever experienced gum recession?

NoYes
Please give us more information on it.
Have you ever been told that you have gum disease/periodontal disease?

NoYes
Please give us more information on it.
Are any of your teeth loose?

NoYes
Please give us more information on it.
Are any of your teeth sensitive or sore to hot, cold, sweets or biting on harder foods?

NoYes
Please give us more information on it.
Do you have any difficulty chewing food?

NoYes
Please give us more information on it.
Have you ever broken or chipped a tooth of filling?

NoYes
Please give us more information on it.
Do you get food caught in between your teeth?

NoYes
Please give us more information on it.
Have you noticed your teeth changing shape or getting shorter?

NoYes
Please give us more information on it.
Do you ever wake up in the morning with head or neck ache? Or pain on your teeth or jaws/face?

NoYes
Please give us more information on it.
Do you grind or clench your teeth?

NoYes
Please give us more information on it. Have you received any treatment for it? For example a night splint/guard.
Do you suffer from reflux or heartburn?

NoYes
Please give us more information on it.
Do you ever feel like your mouth is dry or have any issues with your saliva?

NoYes
Please give us more information on it.
Do you eat or drink very acidic foodstuff? Or used to? For example, lemons, vinegar, salad dressing, etc.

NoYes
Please give us more information on it.
Have you had significant trauma involving your face, head or neck?

NoYes
Please give us more information on it.
Sleep Medicine

You are almost there! We know it is a long form but this information is very important for us.

Please answer these questions about the function of your nose:

	Not a problem	Very mild problem	Moderate problem	Fairly bad problem	Severe problem
Nasal Stuffiness
Nasal blockage or obstruction
Trouble breathing through my nose
Trouble sleeping
Unable to get enough air through my nose during exercise or exertion

Calculation
Understanding your score:

0-25 is indicative of mild obstruction;

25-50 is indicative of moderate obstruction;

50-100 is indicative of severe obstruction;

If you have any degree of nasal obstruction we recommend that you see your GP and an ENT for assessment.
Have you been told that you snore?

NoYes
Snoring is a sign of airway obstruction that can range from annoying and disturbing for your partner to life threatening sleep apnea.

Dont ignore the snore!

We can help you with that.
Have you been told that you hold your breath during sleep?

NoYes

Day time sleepiness scale - Tell us how likely you would be to doze off in these situations:

	Would never doze	Slight chance of dozing	Moderate chance of dozing	High change of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g., theatre or in a meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking with someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in the traffic

Calculation
Understanding your score:

0-10 is considered normal;

11-14 is considered mild excessive sleepiness;

15-17 is considered moderate excessive sleepines;

18-24 is considered severe excessive sleepines;

If you scored above 11 we recommend that you see a sleep medicine specialist

to diagnose and treat the cause of your sleepiness.
Are you happy with the quality of your sleep? Do you feel well rested and ready to tackle the day when you wake up?

NoYes
Good quality sleep is fundamental for a healthy and enjoyable life, we really recommend that you seek help if you are not happy with the quality of your sleep.

We can recommend and refer you on to a sleep specialist.
Is there anything else you would like us to know?
Emergency contact

First NameLast Name
Phone Number

Area CodePhone Number
I confirm that the information provided above is true and correct to the best of my knowledge.
Signature of Patient/Parent/Guardian

Clear
Date

DayMonthYear
Date
Should be Empty:

NEW PATIENT FORM

Medical History

COVID SCREENING

Oral Hygiene Habits

Dental Information

Sleep Medicine