New Patient Form for Adults

Name (Last):

(First/Given):

(MI):

Preferred Name:

Gender:
MaleFemale

Status:
MarriedSingleOtherChild

Birth Date:

Email Address:

Telephone:

Preferred Contact Method:
CellEmailText

Address (Unit#/Street Name):

City/Prov.:

Postal Code:

Emergency Contact Information

Name:

Phone #:

Relationship:

Who referred you to our practice:
SignWebsiteSocial MediaRadioOther (Please specify)
 

Primary Insurance

Employer:

Name of Insured:

DOB (Insured/Plan Holder) (DD/MM/YYYY):

Relationship to Insured:
SelfSpouseChildOther

Plan Name (Insurance Company):

Group/Plan/Policy#:

ID/Certificate#:

Secondary Insurance:

Employer:

Name of Insured:

DOB (Insured/Plan Holder) (DD/MM/YYYY):

Relationship to Insured:
SelfSpouseChildOther

Plan Name (Insurance Company):

Group/Plan/Policy#:

ID/Certificate#:

Medical History (Please check all that apply):

Drug Allergy:
CodeineIbuprofenPenicillinSulfaErythromycinLatexOther

Skin:
AcneEczemaPsoriasisMelanoma

Muscular:
Muscular dystrophy

Cardiovascular/Heart:
AnginaAnemiaBypass surgeryHeart attackHeart murmurLow blood pressureHigh blood pressureHeart diseaseBlood disorderPacemakerRheumatic feverValve replacement

Respiratory:
SinusTuberculosisAsthmaLung

Bone:
ArthritisOsteoporosisJoint Replacement

Urinary:
Kidney disease

Digestive:
UlcersLiver diseaseHepatitis (specify Type)Acid Reflux

Endocrine:
Thyroid diseaseDiabetes (specify Type)

Nervous:
Neurological disorderStrokeMental HealthMultiple sclerosisHead injuryEpilepsySeizuresCreturzfeldt-Jakob (prion)Anxiety

Marijuana Use:
RecreationalMedicinalInhalationEdibleVape Use

Immunodeficiency:
STIHerpes (specify Type)Super bugs MRSA/VREHIV/AIDS

Autoimmune Disease:
LupusRheumatoid Arthritis

Other:
Recreational drug useTobacco useVape UseWeight fluctuationChemotherapySleep apneaInsomniaSteroid useRadiation TreatmentCeliac

Weight:

Height:

Have you been hospitalized or undergone surgery in the past 2-3 years:
YesNo

Have you taken antibiotic premedication for dental treatment?
YesNo

Are you pregnant?
YesNo

Due Date:

Are you breast feeding?
YesNo

Are you currently attempting to conceive?
YesNo

When was your last medical examination?

Are you presently under the care of a physician?
YesNo
 

Please provide the name and phone number of your primary physician:

Dental History:

What is the reason for your dental visit today?

Please check all that apply
Frequent HeadachesJaw/TMJ problemsClenching/GrindingOrthodontics/BracesSleep apneaReceding gumsDry mouth

Do you currently have the following?
Oral device/ApplianceDentureNight guardSports guardOrthodontic retainerOther (specify)
 

How often do you brush your teeth?
Once/dayTwice/day3 Times/daySeldomNo

How often do you floss your teeth?
Once/dayWeeklySeldomNo

Do you have dental anxiety?
YesNo

When was your last visit to the dentist?

What was done at your last dental office?
ExaminationHygieneDental treatment

Authorization to the best of my knowledge, all of the preceding information is true and correct. If there is a change to my health, I am going to inform the office at my next dental apointment without fail. I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or incorrect information has the potential of being hazardous to my health. I understand that I am financially responsible for any outsanding balance for services provided that are not fully covered by insurance

Signature:

Date:

Relationship to Patient:
SelfParent/Guardian

Adult Sleep & Breathing Questionnaire:

Date

Patient's Name

Patient's DOB:

Age

Are you:
MaleFemale

Have you had a sleep test administered?
YesNo
 

Have you been diagnosed with Sleep Apnea?
YesNo

Do you currently use a CPAP or Sleep Appliance for Sleep Apnea?
YesNo

Are you happy with your CPAP or Sleep Appliance?
YesNo
 

How often do you get out of bed to use the restroom during the night?

Do you usually wake feeling tired and unrested?
YesNo

Do you habitually snore?
YesNo

Have you been diagnosed with Hypertension/High Blood Pressure?
YesNo

Do you often suffer from waking headaches?
YesNo

Do you regularly experience daytime drowsiness or fatigue?
YesNo

Do you have blocked nasal passages?
YesNo

Has anyone observed you stop breathing during your sleep?
YesNo

Do you wake up choking or gasping?
YesNo

Do you grind your teeth while sleeping?
YesNo

Is your neck circumference greater than 40 cm/15.75"?
YesNo

Is your Body Mass Index (BMI) more than 35?
YesNo

BMI Formula - Body Mass Index (BMI) = (your weight in pounds*703) / (your height in inches * your height in inches)