Planetsmiles
Name
Prefix
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Ph:
Format: (000) 000-0000.
Mobile Ph:
Format: (000) 000-0000.
Work Ph:
Format: (000) 000-0000.
Email:
example@example.com
Date of Birth:
-
Day
-
Month
Year
Date
Occupation:
Employer:
What are your main concerns?
When was your last dental visit?
Confidential Medical History: Are you, or have you ever been treated for any of the following?
Medical History
Rows
Yes
No
Rheumatic Fever
Artificial Heart Valve
Blood disorders
Hepatitis B
Hepatitis C
HIV/Aids
Heart Disease
Diabetes
High Blood Pressure
Pacemaker
Cancer
Tumour
Epilepsy
Strokie
Asthma
Arthritis
Heart Murmur
Are you pregnant
Any other conditions?
Breathing, Sleep & Airway Screening
The following questions help us understand your airway, breathing and sleep patterns — areas closely linked to dental, jaw and general health.
Do you breathe through your mouth during the day or while asleep?
*
Yes
No
Do you snore?
*
Yes
No
Do you wake feeling unrefreshed, or experience restless sleep?
*
Yes
No
Do you experience daytime fatigue, sleepiness or difficulty concentrating?
*
Yes
No
Do you grind or clench your teeth (during the day or at night)?
*
Yes
No
Have you ever been diagnosed with a tongue tie, or do you find it difficult to rest your tongue against the roof of your mouth?
*
Yes
No
Have your tonsils or adenoids been removed?
*
Yes
No
Do you find it difficult to breathe through your nose?
*
Yes
No
Any additional details you would like us to know about your breathing, sleep or airway (optional)
Allergies Y/N
(Please List):
Are you currently taking any medications?
Please list all current medications, dosages and frequency
Doctors Name:
Telephone:
Format: (000) 000-0000.
Emergency Contact Name:
Relationship:
Home Ph:
Format: (000) 000-0000.
Mobile Ph:
Format: (000) 000-0000.
Work Ph:
Format: (000) 000-0000.
Name of Healthcare Fund:
Membership Number:
Medicare Number:
Position:
Who is responsible for your account?
How would you rate your anxiety levels when visiting the Dentist on a scale of 1 - 10 (1 being the most relaxed and 10 being the most anxious)?
How would you describe your current overall stress level on a scale of 1 - 10 (1 being very calm, 10 being highly stressed)?
*
1
1
2
3
4
5
6
7
8
9
10
10
1 is 1, 10 is 10
How did you find Us? (Please Tick)
Doctor
Dentist
Internet
Phone Book
Friend
Imaging & Photography Consent
As part of your dental assessment and ongoing care, clinical photographs, intraoral scans, X-rays (including OPG and intraoral), and where indicated CBCT (3D cone beam) imaging may be taken. These records are used for diagnosis, treatment planning, and monitoring your progress. Where used for case discussion, professional development or research, identifying details will be removed.
I consent to clinical photographs, intraoral scans, X-rays and CBCT imaging being taken as clinically indicated during my care at Planetsmiles, and to the de-identified use of these records for professional development and research.
*
I consent
Signature:
Date:
-
Day
-
Month
Year
Date
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