New Patient Questionnaire

Personal Information

Name *

Is this patient a child?

Yes

Date of birth *

Gender *

Care card number *

Contact Details

Home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home phone

Cell phone

Work phone

Email *

Person responsible for account (if different than patient)

Referral information

Referrals are very important to us! Who may we thank for referring you to or office, or how did you find us?

Emergency Contact Details

Emergency contact name *

Emergency contact relationship *

Emergency contact phone *

Dental Insurance Information

Do you have dental insurance coverage? *

Medical Information

It is important that we know about your dental and medical history. Information you give us is strictly confidential and will not be released to anyone without your written permission.

Physician's name *

Date of last physical exam *

Has there been any change in your health within the past year? *

Are you now under the care of a physician? *

Have you been hospitalized or had a serious illness within the last 5 years? *

Have you had abnormal bleeding associated with previous extractions, surgery, or trauma? *

Yes
No

For women, are you pregnant?

Yes
No

Are you currently taking any medications? *

Yes
No

Are you allergic to any medications? *

Yes
No

Has your physician ever indicated to you that you require antibiotic premedication prior to dental treatment? *

Yes
No

Have you ever been tested for AIDS/HIV? *

Yes, tested negative
Yes, tested positive
No

Do you have any disease, condition, or problem not listed above? *

Yes
No

Your Dental History

Are you having any discomfort at this time? *

Yes
No

How long has it been since you have been to the dentist? *

Are your teeth sensitive to hot, cold, or sweet?

Hot
Cold
Sweet

Do you have any popping, clicking, or snapping noise when you chew? *

Yes
No

Does your jaw lock if it is open for a long time? *

Yes
No

Do you suffer from headaches or a sore neck often? *

Yes
No

What is the name of your previous dentist?

Why did you leave your previous dentist?

Are you happy with the appearance of your teeth? *

Yes
No

Do you smoke? *

Yes
No