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all information is confidential
Patient Id #

Name

M.I

Last Name

Address

City

Postal Code

Date Of Birth

Age

Sex Male Female

Home Phone

Work Phone

Email:

Cell Number

Marital Status

Whom may we think for referring you

In Emergency Notify

Relationship

Phone

Family Physician

Phone

Primary Dental Insurance

Relationship

DOB

Employer

Occupation

Insurance Carrier

Group/Policy #

D/SIN #

Signature Required:
Submission Assignment Non-Assignment
Secondary Dental Insurance

Relationship

DOB

Employer

Assignment Non-Assignment

Occupation

Insurance Carrier

Group/Policy #

D/SIN #

Signature Required: Yes No
Submission Assignment Non-Assignment
Dental History

Please appropriate boxes

1. When was your last cleaning and check-up appointment?

2. Are any of our teeth sensitive to Cold Sweet Heat Other
3. Do your gums bleed when Brushing Flossing Spontaneously
4.Do you suffer from pain and /or swelling of your gums? Yes No
5.Are you aware of any loose teeth? Yes No
6.Do you chew on only one side of your mouth? Yes No
7.Habits Bite your lips or cheeks regularly? Grind or clench your teeth during the day or night? Hold any foreign objects with your teetn? eg. pencils Mouth breathe while awake or asleep?" "Bite your nails?
8.Does any part of your mouth hurt when clenched? Yes No
9.Does your jaw crack or pop when opened widely? Yes No
10.Do you have any difficulty in opening or closing your jaw? Yes No
11.Have you had any of the following: Oral Surgery Gum Surgery Braces Other appliances
12.Have you experienced any growth or sore spots in your mouth Yes No

13.Are you concerned about the appearance of your teeth and if so, what would you like to see changed? specify:

14.Would you rate your current dental health as: Excellent Good Fair Poor
15.Is your sugar intake: High Medium Low
16.Brushing: Vigorous Light How Often
17.Cleaning aids presently used: Floss Stimudents Toothpick Other
18. Do you have any emotional concerns regarding you dental visit Fear Time Money Embarrassment Pain
19. Do you have any other concerns?
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