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Call US : +1 905-477-6333

Home
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Insurance
About Us
- Meet Our Doctors
- Meet our Team
Contact Us
- Appointments
- Dental Forms
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Dental History Form

Dental History Form

To assist the dentist and ensure your well being while undergoing treatment in our office please answer the following questions in detail.
Information will be considered confidential and for our records only.

IF YOU HAVE QUESTIONS OR DESIRE ASSISTANCE PLEASE ASK RECEPTIONIST.

Dental History

Prefix

First Name *

Middle Name

Last Name *

REASON FOR INITIAL VISIT

LAST DENTAL VISIT

LAST DENTAL CLEANING

LAST FULL MOUTH SERIES X-RAYS

Are you suffering from pain now?YesNO

Do you have any sensation of the lips, tongue?YESNO

Are any of your teeth becoming loose ?YESNO

Does your mouth tend to get dry?YESNO

Does your mouth tend to get dry?YESNO

Ate you aware of bad breath or bad taste in your mouth ?YESNO

Is there any swelling or pain on your gums?YESNO

Are you nervous about having dental treatment done?YESNO

Do you notice any bleeding from your gums when you brush your teeth, or others?YESNO

Is there any history of gum disease in your family?YESNO

Have you ever had an upsetting experience in a dental office?YESNO

EXPLAIN ( If YES)

Treatments : Please check off the following treatments you have had :

A) Orthodontic Treatment?YESNO

B) Oral Surgery?YESNO

C) Periodontal Treatment?YESNO

D) Teeth ground or bite adjusted?YESNO

E) Worn a bite plate or other appliance?YESNO

Jaw Problems : Do you have any of the following :

A) Clicking of the jaw when opening or closing ?YESNO

B) Pain (in jaw joints — ear, side of face?)YESNO

C) Difficulty in opening or closing your mouth?YESNO

D) Difficulty in chewing?YESNO

Habbits : Do you ?

A) Clench or grind your teeth while awake or asleep?YESNO

B)Bite your lips or cheeks regularly?YESNO

C) Hold foreign objects with your teeth (such as pencils, pipe, pins, nails, fingernails)?YESNO

D) Breath through your mouth while awake or asleep ?YESNO

E) Is it important to you to keep your teeth clean?YESNO

F) Are you unhappy with the appearance of your teeth?YESNO

How often do you brush your teeth?

How often do you Floss your teeth?

What would you like to change with your teeth?

WELCOME TO OUR OFFICE!

At this office we would like to provide you with quality dental treatment and total patient care. Your treatment recommendations will be based on a thorough examination and diagnosis. A written estimate can be sent to your insurance company to determine the extent of your coverage for specific procedures. Your appointment time will be reserved especially for you. If you are unable to keep an appointment, we will require 24 hours notice; otherwise it may be necessary to charge for time lost.

I understand that Iam financially responsible to the dentist for all necessary treatment even if my insurance coverage may not be all inclusive.

I wish to pay each visit as services are performedCASHCHEQUECREDIT CARDI wish to discuss special arrangements for payment

Interest of 2% per month on late payments will be charged automatically.

Date

Name

{name-1-prefix} {name-1-first-name} {name-1-last-name}

Signature *

Start signing your signature here

A HEALTHY SMIILE IS ALWAYS IN STYLE

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