The following information is required to enable us to provide you with the best possible dental care. All information is strictly rivate, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form
If yes, please explain?
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year?yesNo
If yes, please explain.
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? YesNo
If yes, please list them.
5. Do you have any allergies or had a bad reaction to any medications? YesNo
a) medications
b) latex/rubber products
c) other (e.g. hay fever, seasonal/environmental, foods)
6. Do you have or have you ever had asthma? YesNo
7. Do you have or have you ever had any heart or blood pressure problems? YesNo
8. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart 1 (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? YesNo
9. Do you have a prosthetic or artificial joint? YesNo
10.Do you smoke or chew tobacco products? YesNo
11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? YesNo
12. Have you ever had hepatitis, jaundice or liver disease? YesNo
13. Do you have a bleeding problem or bleeding disorder? YesNo
14.Have you ever been hospitalized for any illnesses or operations? YesNo
If yes please explain
15. Are you currently pregnant or breastfeeding? YesNo
Dental History
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
Have you ever had trouble getting numb or had any reactions to local anesthetic? YesNo
Do your gums bleed or are they painful when brushing or flossing? YesNo
Have you ever had any teeth become loose on their own (without an injury)? YesNo
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? YesNo
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? YesNo
Do you frequently get food caught between any teeth? YesNo
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) YesNo
Do you clench or grind your teeth together in the daytime or make them sore? YesNo
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of
your teeth? YesNo
Do you wear or have you ever worn a bite appliance? YesNo
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? YesNo
Have you felt uncomfortable or self-conscious about the appearance of your teeth? YesNo
Consent for Collection, Use and Disclosure of Personal Information.
I agree that Deep Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed asset out in the Privacy Policy and is in accordance with the Personal Health Information Protection Act,2004.