Oakville

231 Oak Park Blvd., Suite #108

Oakville, ON L6H 7S8

info@chaggerdental.com

(905) 123-4567

CHAGGER DENTAL PATIENT INFORMATION

Submitted: {{SUBMISSION_TIMESTAMP}}

Patient Profile

Title

Full Name

Age

Sex

Marital Status

Date of Birth

Street Address

City

Province / State

Postal Code

Email Address

Home Phone

Cell Phone

Occupation

Employed By

Dental Insurance & Care Providers

Dental Insurance?

Company

Policy No.

ID / Cert No.

Family Physician

Physician Phone

Previous Dentist

Phone No.

Referral Credit

Emergency Contact

Contact Name

Relationship

Address

Phone Number

Confidential Medical History

1. Date of last complete physical examination	{{MED_Q1}}
2. Are you currently under a physician’s care? {{MED_Q2_SPECIFY}}	{{MED_Q2}}
3. Do you have frequent headaches?	{{MED_Q3}}
4. Do you smoke?	{{MED_Q4}}
5. Do you drink alcohol {{MED_Q5_SPECIFY}}	{{MED_Q5}}
6. Do you do recreational drugs?	{{MED_Q6}}
7. Do you routinely take vitamins, herbal substances, or natural products? {{MED_Q7_SPECIFY}}	{{MED_Q7}}
8. Are you taking any medications? {{MED_Q8_SPECIFY}}	{{MED_Q8}}
9. Have you taken any prolonged medication in the past? {{MED_Q9_SPECIFY}}	{{MED_Q9}}
10. Have you taken cortisone or steroids?	{{MED_Q10}}
11. Have you ever been hospitalized for any surgery? {{MED_Q11_SPECIFY}}	{{MED_Q11}}
12. Are your ankles often swollen?	{{MED_Q12}}
13. Have you gained or lost excessive weight recently?	{{MED_Q13}}
14. Are you pregnant? {{MED_Q14_SPECIFY}}	{{MED_Q14}}

15. Sensitivity/Adverse reactions

16. Allergies/Adverse reactions

17. Other allergies or adverse reactions to any other drugs?

18. Treated for or told you have any of the following:

19. Have you ever experienced heavy bleeding?	{{MED_Q19}}
20. Is there anything else we should know? {{MED_Q20_SPECIFY}}	{{MED_Q20}}
21. Have you been diagnosed with any other disease, condition or problem?	{{MED_Q21}}
22. Is there anything about your health we should be aware of? {{MED_Q22_SPECIFY}}	{{MED_Q22}}
23. Do you wish to speak to the doctor privately?	{{MED_Q23}}

Confidential Dental History

27. Date of last complete exam	{{DEN_Q27}}
28. Date of last cleaning	{{DEN_Q28}}
29. Date of last x-rays	{{DEN_Q29}}
30. Did you see your last dentist regularly?	{{DEN_Q30}}
31. How often did you see your last dentist? Was done: {{DEN_Q31_DESC}}	{{DEN_Q31_FREQ}}
32. Have you ever been advised to take antibiotics?	{{DEN_Q32}}
33. Have you ever experienced heavy bleeding following extractions?	{{DEN_Q33}}
34. Have you ever had gum treatment or surgery?	{{DEN_Q34}}
35. Have you had any orthodontic treatment?	{{DEN_Q35}}
36. Have you ever had an unpleasant dental experience?	{{DEN_Q36}}
37. How can we make your experience more pleasant?	{{DEN_Q37}}
38. Is there anything else we should know?	{{DEN_Q38}}
39. What brings you to the office today?	{{DEN_Q39}}
40. Are you in any discomfort? {{DEN_Q40_SPECIFY}}	{{DEN_Q40}}

41. Do you have or have you experienced:

42. Does food get caught between your teeth?	{{DEN_Q42}}
43. Do you have any sore spots in your mouth?	{{DEN_Q43}}
44. Have you had any teeth replaced?	{{DEN_Q44}}
45. Interested in permanent tooth replacement?	{{DEN_Q45}}
50. Have you ever been given local anesthesia?	{{DEN_Q50}}
51. Have you ever been given general anesthesia?	{{DEN_Q51}}
52. Are you satisfied with the appearance of your teeth?	{{DEN_Q52}}
53. Are you anxious to keep your natural teeth?	{{DEN_Q53}}
54. Are you tense during dental visits?	{{DEN_Q54}}
55. Interested in method to calm your nerves?	{{DEN_Q55}}

56. How can we help you today?

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