location_on 805 Development Dr ❘ Kingston, Ontario K7M 4W6
call(613) 389-8660
mail reception@davidgouettdentistry.com

Address

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Fax: 613-389-9003

# New Patient Form

Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.

## 1 REGISTRATION INFORMATION

The patient is an: Adult Child Adult under guardianship
Name of Guardian
Name: Last, First
Initial
Dr. Mr. Mrs. Ms. Miss.
Address: Street
Address 2: Street
City and Prov/State
Zip/Postal code
Reason for today's visit?
Examination Emergency Other
Is there a dental problem you would like treated immediately?
Preferred appt. time?
Home Phone
Cell Phone
Pager No.
Bus. Phone
Employer
May we call you at work?
Yes No
E-mail address
Prefers to be called
Occupation
Date of Birth (M/D/Y)
Age
Sex
Marital Status
Name of Spouse
Are other family members patients at our office?
Yes
Whom may we thank for referring you?
Family Physician
Phone
Medical Specialist (if presently under care)
Phone
In case of emergency, please contact
Phone
Nearest relative not living with you
Phone

## 2 FINANCIAL & CREDIT INFORMATION

Person responsible for account: Self Spouse Other
Name: Last, First
Initial
Home Phone
Address: Street
Address 2: Street
City and Prov/State
Zip/Postal Code
Employed by
Phone
Driver's Lic. No.
S.S.N. / Health Card #
Credit Card No.
Expiry Date

### Primary Dental Insurance

Subscriber's name
D.O.B.
Ins. yr. end
Emp./Grp. policy holder
Ins. Co.
Tel.
Grp./Ind. policy No.
Cert. No.

### Secondary Dental Insurance

Subscriber's name
D.O.B.
Ins. yr. end
Emp./Grp. policy holder
Ins. Co.
Tel.
Grp./Ind. policy No.
Cert. No.

## 3 MEDICAL HISTORY QUESTIONS

1. Are you being treated for any medical condition at the present or have you been treated within the last year?

Yes No Not Sure

2. Has there been any change in your general health in the past year?

Yes No Not Sure
3. When was your last medical checkup?

4. Do you have any conditions that could affect your immune system? (e.g. Leukemia, HIV +/- tested, Lupus)

Yes No Not Sure

5. Are you undergoing any therapies that could affect your immune system? (e.g. Radiotherapy or Chemotherapy)

Yes No Not Sure

6. Are you currently taking any steroids or cortisone?

Yes No Not Sure

7. Do your ankles, feet or hands swell?

Yes No Not Sure

8. Are you allergic to any medications?

Yes No Not Sure
If yes, please list:

9. Are you allergic to any of the following?

Latex Metal Rubber None of the above Not Sure

10. Are you allergic to any foods?

Yes No Not Sure
If yes, please list:

11. Do you have any other allergies that we should be aware of?

Yes No Not Sure
If yes, please list:

12. Have you ever had any peculiar or adverse reactions to any medicines or injections?

Yes No Not Sure
If yes, please list:

13. Are you taking or have you ever taken osteoporosis medications? (e.g. Fosamax, Actonel)

I am currently taking I was previously taking but am no longer No Not Sure
If currently or previously taking, please specify which medication:

14. Are you currently taking any prescription medications?

Yes No Not Sure
If yes, please list:

15. Have you been advised against taking any medications?

Yes No Not Sure
If yes, please list:

16. Are you taking any non-prescription drugs?

Yes No Not Sure
If yes, please list:

17. Do you take any recreational drugs on a regular basis?

Yes No Not Sure
If yes, please list:

18. Are you taking any herbal supplements of any kind?

Yes No Not Sure
If yes, please list:

19. Do you have diabetes?

I have Type 1 Diabetes I have Type 2 Diabetes No Not Sure

20. Do you have or have you ever had any of the following?

Arthritis/Rheumatism Asthma Cancer Chest Pain/Angina Crohn's Disease Drug/Alcohol Dependency Fainting or Dizzy Spells Glaucoma Hay Fever Head/Neck Injuries Heart Attack Hepatitis A Hepatitis B Hepatitis C Herpes - Oral/HSV-1 Hyperglycemia Hypoglycemia Jaundice Kidney Disease Liver Disease Lung Disease/Emphysema Malignant Hyperthermia Mitral Valve Prolapse Pacemaker Psychiatric/Mental Disorders Rheumatic/Scarlet Fever Seizures (Epilepsy) Shortness of Breath Sickle Cell Disease Sinus Trouble Stomach Ulcers Hay Stroke Thyroid Disease Tuberculosis

21. Do you have or have you had any conditions or diseases not previously listed that we should be aware of?

Yes No Not Sure
If yes, please list:

22. Are there any diseases or medical problems that run in your family?

Cancer Heart Disease Diabetes Malignant Hyperthermia
Other

23. Do you have a bleeding problem or bleeding disorder?

Yes No Not Sure

24. Do you have or have you ever had a replacement or repair of a heart valve or stent?

Yes No Not Sure

25. Do you have or have you ever had an infection of the heart? (e.g. Infective Endocarditis)

Yes No Not Sure

26. Have you had a transplant (heart, lungs, organs)?

Yes No Not Sure

27. Do you have a heart condition from birth? (e.g. congenital heart disease/lesions)

Yes No Not Sure

28. Do you have or have you ever had any heart or blood pressure problems?

Yes No Not Sure

29. Do you have a prosthetic or artificial joint?

Yes No Not Sure

30. Have you ever been hospitalized for any illnesses or operations?

Yes No Not Sure

31. Have you ever had any injury or surgery to your face or jaws?

Yes No Not Sure

32. Do you smoke or chew tobacco products?

Yes No Not Sure

33. Are you nervous during dental treatment?

Yes No Not Sure

34. Is there anything else about your health that we should be made aware of?

Yes No Not Sure
If yes, please provide very brief details:

35. Do you wish to speak to the doctor privately about any problem or medical condition?

Yes No Not Sure

36. Has the child patient recently had any of the following?

Chicken Pox Measles Mumps Chest Strep Throat Tonsilitis None/None Applicable

37. Are there any immunizations that the child is not up to date with?

Yes No Not Sure

38. Are you chestfeeding?

Yes No Not Sure

39. Are you pregnant?

Yes No/Not applicable Not Sure