In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

NOTE: Fields marked with an asterisk (*) are required.

PATIENT INFORMATION

Title:

Patient Name:*

CONTACT INFORMATION

Previous Dentist:

Why did you leave your last dentist?

How often do you have you teeth cleaned?  3-6 months  Annually  Other:

What is your IMMEDIATE dental concern?

Date of your last dental visit?  

Date of your last dental X-Ray?  

Please select YES or NO to the following:

1. Are you satisfied with the appearance of your teeth?

 Yes   No 

If no, please specify:

2. Did you have any unfavourable dental experiences?

 Yes   No 

3. Do you have dental fears?

 Yes   No 

4. Are you nervous about your dental treatment?

 Yes   No 

5. Problems with effectiveness or bad reactions to dental anesthetic?

 Yes   No 

6. Bleeding gums?

 Yes   No 

7. Avoid brushing any part of your mouth?

 Yes   No 

8. Sensitive to temperature? (hot or cold)

 Yes   No 

9. Does food get caught between your teeth?

 Yes   No 

10. Sore teeth?

 Yes   No 

11. Burning sensation in your mouth?

 Yes   No 

12. Difficulty swallowing?

 Yes   No 

13. An unpleasant taste or odour in your mouth?

 Yes   No 

14. Dry mouth?

 Yes   No 

15. Jaw problems (temporomandibular joint or TMJ)?

 Yes   No 

16. Stiff neck muscles?

 Yes   No 

17. Tension headaches?

 Yes   No 

18. Clench or grind your teeth?

 Yes   No 

19. Lost any teeth?

 Yes   No 

Do you have or have you had any of the following procedures? Please check all that apply:

Bridgework
Crowns or Caps
Dentures or partial dentures
Orthodontics (braces)
Periodontal (gums)
Root canal treatment
None of the above

Please elaborate if you have any of the above:

Supplemental Denture History:

If you are wearing a partial or complete artificial denture, please complete the following:

  • Has your present denture been relined? When? 
  • Is your present denture a problem? Describe: 
  • Are you satisfied with your appearance? 
  • Are you satisfied with your chewing ability? 
  • When did you receive your first partial or complete denture? 
  • How long have you worn your present denture? 
CONSENT
 I acknowledge that the information given to me is true to the best of my knowledge and that the questions have been reviewed with me. Should there be any changes to my present health status in the future, I will advise Clinton Dental. I have been informed that my physician may be contacted by letter, email, fax, or telephone in order to complete details of my medical history. I hereby consent to my physician providing Clinton Dental with any information in this regard which may ensure safe dental treatment. Finally, I hereby acknowledge that dental treatment may be delayed until all medical information required by Clinton Dental is received.


Patient Name*:
Date*:
Patient Initials*: