PATIENT - INFORMATION SUBMITTED ON THIS FORM ARE SECURE

How did you find out about us / who referred you?
Surname: First: Middle: Initial: Title
Phones: Res: - - Business: - ext:
Date of Birth: mm dd yyyy
Address: (No. and Street) Apt. No. City:
Postal Code: Province
Employer: Occupation:
Email (name@server.domain)
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INSURANCE - INFORMATION

Insurance Company Group Policy Number:
Certificate Number: Division:



MEDICAL - HISTORY

PLEASE NOTE:
The following information is essential for proper diagnosis and treatment. It is also extremely important for your safety!
PLEASE READ CAREFULLY AND FILL OUT COMPLETELY:
All information is CONFIDENTIAL and cannot be released to ANYONE without your consent.

1. Your Physician's Name: Address:
2 . Date of Last visit: Reason:
3. What medication(s) are you taking?
4. What medication(s) are you ALLERGIC to?

PLEASE CHECK EITHER (YES) OR (NO) FOR ALL OF THE FOLLOWING.
5. Have you ever had ANY adverse reactions to, or been advised NOT to take any of the following medication(s)?

Anti-inflammatories:
Erythromycin:
Local anaesthetic:
Aspirin:
Penicilin:
General anaesthetic:
Codeine:
Tylenol:
Nitrious oxide
Laughing gas:
Other MEDICATIONS?

6. Have you ever had ANY adverse reaction to contact with the following?
Sulfites -
food preservative:
Latex -
rubber gloves balloons:
PABA - (sunscreen):
Nickel - (costume jewelry):

7. Have you ever had, or been treated for, or do you currently have ANY of the following?

Addiction:
Epilepsi:
Kidney Disease or Dialysis:
Allergy:
Heart Attack,
Corronary Disease
or Heart Surgery:
Mental Ilness, Anxiety
Depression:
Anemia, Blood Disorders:
Heart Murmur,
Miltral Valve Prolapse,
Rheumatic Fever:
Prosthetic Valves,
Joints or Plates:
Arthritis:
High/Low
Blood Pressure:
Sinusitis:
Asthma:
TB or Lung Disease:
Stroke:
Cancer:
HIV:
Thyroid problem:
Diabetes:
Hepatitis:
Ulcer:
Eating Disorders:

8. List ANY serious illness you have had:

9. List ANY operations you have had:

10. Have you ever fainted?: Do you experience shortness of breath?: Chest pains?:

11. Do you require an extra pillows when recline or sleep?: Do your ankles swell?:
12. Has your weight changed recently?: What amount?
Are you now or have you ever been on a diet?: If YES, for what reason?
13. Do you bruise easily or bleed abnormally?: Is there any history of family disease?:
If yes, list:
14. WOMAN ONLY: Are you pregnant?: How many months? Are you nursing?:


DENTAL - HISTORY
1. Have you ever had any injury, surgery or radiation therapy on your face or jaw?:
If so, describe:

2. Have you ever had a complete set or x-rays or a panorex taken?: If so, when
3. When was your last dental visit? Purpose?
Were x-rays taken?:
4. What dental condition concerns you at present?
5. What is the history of this condition?
6. Have you had regular (annual or semi-annual) dental examinations in the past?:
If not, why not?
7. Have you had ANY teeth extracted?: If so, when
Describe any complications
8. Have you had local anaesthetic?: Describe any adverse reactions
9. Are you conscious of bad breath conscious of bad breath?:
Do your gums ever feel itchy, swollen or bleed?:
10. Have you ever been instructed on proper home care of your mouth?:
Do you use floss?: Rubber tip?:
11. Do you chew easily and throughly?: Which side do you chew on?: Not sure
12. Are you aware of clenching or grinding your teeth?: Does your jaw ever click, crack or lock?:
Which side? side::
13. Does it ever get stiff or painful?: Have you ever had TMJ therapy?:
If so, describe:
14. Are you tense during dental visits? Have you ever had Nitrious Oxide (laughing gas)
for dental treatment?:
15. Are you satisfied with appearance of your teeth?: What would you change?
16. Are you interested in discussing cosmetic options (re: possible
changes to tooth color, shape
spacing or position?:
17. Is there any other information you think could be a factor in determining your treatment?:
If so, explain

I, the undersigned certify that I have read and understand all of the above questions, and that all of the above information is correct and that I have not omitted any pertinent information, I also authorize release, to my insuring company/plan administrator, the information contained in claims submitted electronically.


SMILE - QUIZ
Please check only ONE answer, most applicable to your situation!
1. Color of teeth
1
Not satisfied

 2
 3
Somewhat satisfied		 4 5
Very satisfied

2. Crooked or overlapping teeth

1
Not satisfied

 2
 3
Somewhat satisfied		 4 5
Very satisfied

3. Presence of cracks/chips/missing teeth

1
Not satisfied

 2
 3
Somewhat satisfied		 4 5
Very satisfied

4. Size/lenght of teeth

1
Not satisfied

 2
 3
Somewhat satisfied		 4 5
Very satisfied

5. Presence of gummy smile

1
Not satisfied

 2

 3
Somewhat satisfied		 4 5
Very satisfied