'",oit#on lake bonavista

Mr/Mrs/MsiDr.

NicknameHome Address

OccupationCellular

Today's Date

Date of BirthDay/Month/Year

Day/Month/Year

Postal CodeTelephoneTelephone

EmailHow and Where do you prefer to be contacted?

Whom may we thank for referring you to our office?Other family members who come to our office?

Emergency Contact TelephoneName of Physician TelephoneWhat is your estimate of your general health? Poor- Fair- Good

Do you have Dental Insurance? INSURANCE INFORMATIONPolicy Holder Name: Date of Birth

Day/Month/Year

Employer Telephone

Insurance CarierDual Plan

Policy #

lder Name: Date of BirthDay/Month/Year

Telephone

Insurance Carrier Policy # Cert #

MEDICAL AND DENTAL INFORMATIONYour safety and optimal oral health care are our priorities. The following information enables us to provide you with the best oral health care

services safely and effectively. Please complete the entire form. During your visit, you will be asked questions regarding your questionnaire

responses. All information is confidential and treated in accordance with applicable provincial and federal privacy legislation.

GENERAL INFORMATIONI When was yorr last medical checkup? Date:

Are you being treated for any medical condition or have you been treatedwithin the past year?

Y N

Has there been anv chanse in vour seneral health in the last vear? Y N+. Have vou ever been hospitalized for any illness or operation? Y N

Div: Cert #

Policy Ho

Employer

Div:

Height- Weight - BMI-

5. Do you have a prosthetic or artificial ioint (i.e. hip, knee)? Y N5. Have you ever been advised to take antibiotics before dental treatment? Y N7. Have you ever had a peculiar or adverse reaction , including allergies, to

anv medication or iniections?Y N

8. Do vou have anv allersies to anv foods or materials (i.e. latex metals)? Y N). Do vou have anv other allersies (i.e. hav fever. animals)? Y NI 0. Do vou have or have vou been treated for cancer Y N11. Doyouhavedrymouth? Y NDo vou have or have vou ever had:12. Ear or hearins oroblems? Y N13. Do you wear a hearins aid? Y N14. Eye Problems (i.e. require corrective lenses, contacts, glaucoma)? Y N15. Sleeo Disorders? Y NWomen6. Are you or could you be pregnant?

Ifves. expected deliverv date:

Y N

17. Are you breastfeeding? Y N18. Are vou takins hormone reolacement theraov? Y NPlease explain any YES answers

9. Are you taking medications of any kind? Include prescribed drugs, over-the-countermedications (i.e. cold and flu remedy), and natural health products (i.e. vitamins, herbal, anddiet supolements). If ves. please list:

Drug Name {.mount, Dose, Frequency'i.e. One 80mg tablet 3 times daily)

Reason Date Prescribedand Prescriber

Dental InformationI Are vou happy with the appearance of your teeth? Y N

Have vou had anv unfavourable dental exoeriences? Y NDo vou have anv dental fears? Y NAnv oroblems with effectiveness or bad reactions to dental anesthetic? Y NHave vou ever had orthodontic treatment (i.e. braces. appliances)? Y NHave you had any periodontal (2m) treatment? Y NDo vour sums bleed when vou brush? Y NAre your teeth sensitive to hot, cold, sweets, or pressure? Y N

). Do vou have a burnins sensation in your mouth? Y N

t0. Do you have any difficulty swallowing? Y N1 1. Do you have an unpleasant taste or odour in your mouth? Y N12. Do you have dry mouth. throal or eves? Y N13. Have you ever had an iniury to your head. face" or iaw? Y N14. Do you have iaw problems (temporomandibular ioint)? Y N5. Do you have difficulty opening your mouth widely? Y N6. Do you have stiff neck muscles? Y N7. Do you awaken with an awareness of your teeth or iaws? Y N8. Are you aware of any clicking or poppins of your iaw? Y N9. Do you clench or grind your teeth? Y N

10. Do you sufler from frequent headaches? Y Nl. Do you have earaches or neck pains? Y N

12, Have you lost any permanent teeth? Y N,"3. Do you have removable dental appliances? Y N,.4. Are you nervous during dental examinations? Y NPlease explain any YES Answers

Mhat is the reason for your dental visit?)ate of last dental examination?)ate of last dental x-rays?)ate of last dental cleaning?{ow often do you have your teeth cleaned?iupplemental Denture History:f you are wearing apartial or complete artificial denture, please complete the followine{as your present denture been relined?s your present denture a problem? Describe Y N

\re you satisfied with the appearance? Y N\re you satisfied with the comfort? Y N\re you satisfied with the chewins abiliW? Y NWhen did you receive your first partial or complete denture?low long have you wom your present denture?

Medical Information

Cardiovascular/Respiratory

Do you have or have you ever had:1. Cardiovascular diseases? If yes,

specifu below:Y N

I Anginafl Arteriosclerosistr Artificial heart valveE Congenital heart defectsE Congestive heart failuren Coronary artery diseaseE Damaged heart valvestr Heart Attack

Heart murmurHigh or low bloodpressure

D High or low cholesteroltr Mitral valve prolapsedE Pacemaker/defi brillatorE Nreumatic heart

disease/feverI Scarlet fever

trtr

Chest pains upon exertion? Y NShortness ofbreath? Y NAsthma? Y NChronic bronchitis or emohvsema? Y NSinus trouble or nasal coneestion? Y NTuberculosis Y NA persistent cough for more than 3

weeksY N

Coush that produces blood? Y NPlease explain any YES Answers

Endocrine/Digestive

Do you have or have you ever had:1. Malnutrition? Y N2. Eatins Disorder? Y N3. Dietary restrictions (self-imposed or

doctor prescribed)?Y N

4. Slow healins or recurrent infections? Y N5. Nisht sweats? Y N6. Thvroid or oarathvroid disease? Y N7. Diabetes? If Yes- indicate tvoe? Y NPlease explain any YES answers:

Immune System/Infectious Diseases

Do you have or have you ever had:I . Svstemic luous enthematosus? Y N2.Painful swollen joints or rheumatoid

arthritis?Y N

3.HIV/AIDS? Y N4.Other diseases or conditions that affect

your immune system (i.e. sarcoidosis,Epstein-B arr, radiotherapy,chemotherapv" steroid therapv)?

Y N

5. Sexually transmitted diseases (i.e.Hemes)

Y N

Please explain any YES answers:

Gastro inte stinaVGenitourinary

Do vou have or have vou ever had:1. Heoatitis- iaundice- or liver disease? Y N

Difficulw swallowins? Y NG.E. refl ux/persi stent heartburn? Y NA stomach ulcer? Y NGall bladder oroblems? Y N

i. Kidney or bladder trouble? Y NExcessive urination? Y N

Please explain any YES answers:

\_

To the best of my knowledge, the above information is correct

Client/Parent/Gaurdian Signature : Date:

Neurolo gicaVMusculoskeletal

Do vou have or have vou ever had:

1. A stroke? Y N2. Convulsions or seizures (i.e. epilepsy)? Y N3. Mental health disorders? Y N4. Arthritis? Y N5. Osteooorosis or osteooenia? Y N6. Chronic nain? Y NPlease explain any YES answers:

Hematologic

Do vou have or have vou ever had:1. Prolonged or abnormal bleeding with a

simple cut or following surgery,extraction or an accident?

Y N

A blood transfusion? If yes. date? Y NA tendencv to bruise easilv? Y NAny blood disorder (i.e. anemia orhaemoohilia)?

Y N

Please explain any YES answers:

Other

1. Do you smoke or chew tobaccoproducts?

Y N

Ifves: Freouencv? (Dailv. Weeklv)Have vou ever tried to quit? Y NAre you interested in quittine? Y NDo you have a drug or alcoholdenendencv

Y N

Other diseases or medical problems thatrun in your family?

Y N

Other conditions or medical problemsnot listed?

Y N

Other special needs that will affect yourdental care?

Y N

Please explain any YES answers:

Reviewed by: (DDS/RDH) Date: