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Dental History Please ✓ yes or no to each question. if unsure of a question, please consult with the dentist or receptionist.
Is there a dental problem you would like treated immediately? Yes ■ Problem: ___________________________________ ■ Noyes no
Are there any other dental conditions that concern you at present? Yes ■ Condition:_______________________________ ■ No
Date of your last dental visit? ________________ Last dental cleaning?_________________ Last x-rays? __________________
1.  Have you been seeing a dentist regularly? __________________________________________________________________ ■ ■
2.  Have you ever had any of the following? YES NO YES NO
-Periodontal Treatment? (treatment of the gums) ■ ■ -Dentures or Partial Dentures? (circle) ■ ■ -Orthodontic Treatment? (to straighten or realign teeth) ■ ■ -Root Canal Treatment? ■ ■ -A night guard or any other appliance? ■ ■ -Dental Implants? ■ ■ -Crowns or Bridges? ■ ■ -Extractions (tooth removal)? ■ ■ -If Yes, did you have prolonged bleeding after? ■ ■ 3.  Are there any growths or sore spots in your mouth?___________________________________________________________ ■ ■
4.  Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?____________________ ■ ■
5.  Have you noticed any loose teeth or have any of your teeth shifted? ______________________________________________ ■ ■
6.  Does food catch between your teeth? ______________________________________________________________________ ■ ■
7.  Are any of your teeth sensitive to heat, cold, sweets or pressure? (circle) __________________________________________ ■ ■
8.  Have you ever experienced any of the following jaw problems:
-Popping/clicking in your jaw joints? ■ ■ -Do you ever get ‘tension’ headaches? ■ ■ -Difficulty in opening or closing? ■ ■ -Do you ever get ‘migraine’ headaches? ■ ■ -Pain when teeth are clenched? ■ ■ -Do you ever get headaches in the right or left temple areas? ■ ■ -Pain or difficulty while chewing? ■ ■ -Does your jaw ever lock open or closed? ■ ■ -Pain in your jaw joints, around your ear, or side of your face? 9.  Do you have any of the following habits?
-Clenching or grinding your teeth while awake or asleep? ________________________________________________ ■ ■
-Biting your cheeks or lips? ________________________________________________________________________ ■ ■
-Mouth breathing while awake or asleep? _____________________________________________________________ ■ ■
-Gag reflex: slight____ moderate____ severe__________________________________________________________ ■ ■
10. Are you missing any teeth? ■ Yes ■ No If so, have they been replaced? ■ Yes ■ No If not, would you like them replaced?
11. Are you unhappy with the appearance of your teeth? __________________________________________________________ ■ ■
and what would you like to see changed? _______________________________________________________________
12. Do you have any concerns about halitosis (bad breath)? _______________________________________________________ ■ ■
13. Are you interested in any of the following? (Please ✓)
■ Teeth whitening or bleaching ■ Cosmetic dentistry    ■ Orthodontic treatment 14. Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment or do you have any questions or concerns?____________________________________________________________________ ■ ■ ____________________________________________________________________________________________________
OFFICE POLICY
APPOINTMENTS
Please help us maintain the operation of our office on sound principles so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you; therefore at least 48 business HOuRs
nOTiCe MuST be given if cancellation is absolutely necessary.
PAYMENT OF FEES
1. Office policy is that services are paid for at each visit as they are performed. However, in certain circumstances arrangements for
payment may be made by consulting the doctor.
2. Regarding insurance: All professional services are CHARGeD DiReCTLY TO THe PATienT AnD PATienTs ARe PeRsOnALLY ResPOnsibLe fOR PAYmenT Of biLLs On THeiR ACCOunTs. We will prepare any necessary forms or reports to help collect your benefits from insurance companies.
GENERAL RELEASE
i, the undersigned, certify that i have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information.
i, the undersigned, hereby authorize the dentist and/or staff members to collect, use and store x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs. i authorize the doctor to performany and all forms of treatment, medication and therapy, that may be indicated and consent to the use of local anaesthetic agents. i under-stand the above statements regarding the payment of fees and accept the responsibility for payment for Dental services provided for my-self or my dependents, due and payable when services are rendered unless other financial arrangements have been made.
i also consent to the collection, use, retention and disclosure of personal information as is required for my own and my dependents den- Patient signature: _____________________________________________ Date: ________________ Witness: ______________________________
Parent or Responsible Party: __________________________________________________________ Relationship to Patient: _________________
Dental History
MeDiCal History UPDates
MeDiCal History UPDates
MeDiCal UPDate Patient siGnatUre
staFF initials
PPb enterprises inc. 1-877-480-2284 form #5049 WElcoME To ANchor dENTAl grouP
MEdIcAl AlErT
date________________________________________
your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All
information is strictly confidential and will remain with this office. our receptionist is available to assist you with the
completion of this form. PlEAsE PrINT.
rEgIsTrATIoN INForMATIoN
The patient is a: Child ■ Adult ■ Adult under guardianship ■ Name of Guardian: ____________________________________________
Name:___________________________________________________________________________________ Dr. ■ Mr. ■ Mrs. ■ Ms. ■ Miss ■
Address: ____________________________________________________________________________________________________________________________
(street) (apt.#) (city) (province) (postal code) Reason for today’s visit? Examination ■ Other ■ ________________________________________________________________________________
Health Card #: _________________________________ Preferred appt. time? _______________________________________________________________
Home Phone: (    ) ____________________ Bus Phone:   (    ) ____________________ Ext. ______ May we call you at work? ■ ■
PErsoNAl INForMATIoN
Prefers to be called: _______________________________________________ Occupation:_____________________________________________________
Date of Birth: M _____ D _____ Y _____ Sex: ______ Marital Status: __________ Name of Spouse: _______________________________________
Are other family members patients at our office? Yes ■ Names:____________________________________________________________________
How did you hear about our office? ■ Friend/Relative ■ Yellow Pages ■ Internet/Website ■ Other ______________________
Whom may we thank for referring you? _____________________________________________________________________________________________
MEdIcAl PrIorITy
Family Physician _________________________________________________________________________________ Phone: (    ) ___________________
Medical Specialist: _______________________________________________________________________________ Phone: (    ) ___________________
(if presently under care)
In case of emergency, please contact: _____________________________________________________________ Phone: (    ) ___________________
FINANcIAl INForMATIoN
Person responsible for account: Self ■ Spouse ■ Other ■ __________ Please complete all information if different than above.
Name:____________________________________________________________________________________________ Phone: (    ) ___________________
Address: ____________________________________________________________________________________________________________________________
(street) (apt. #) (city) (province) (postal code) Employed by: ____________________________________________________________________________________ Phone: (    ) ___________________
Driver’s Lic. No. _________________________________________________________ S.I.N. ___________________________________________________
METhod oF PAyMENT (For office use only) cAsh ■ chEquE ■ crEdIT cArd ■ dEbIT ■
PATIENT rEgIsTrATIoN
MEdIcAl hIsTory
Please ✔ yEs or No to each question. If unsure of a question, please consult with the dentist or receptionist. yEs No
1.  Are you being treated for any medical condition at present or within the past two years? If yes, please explain: ____________________ ■ ■
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
2.  Have you been hospitalized in the past two years?_______________________________________________________________________________ ■ ■
3.  When was your last visit to a Physician?______________________ Last complete physical examination? _____________________________
4.  Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs? Please list: ■ ■
1. ______________________________________ 2. ______________________________________ 3._________________________________________
4. ______________________________________ 5. ______________________________________ 6._________________________________________
5.  Have you ever reacted adversely to any of the following? (Please circle.) ANTIBIOTICS - Penicillin, Keflex, Dalacin, ■ ■ Sulfa, or other antibiotics, ASPIRIN, VALIuM, CODEINE, NARCOTICS, LOCAL ANESTHETIC (freezing),
any other medicine: ____________________________________________________________________________________________________________
6.  Have you ever been advised against taking any specific type of medication? _____________________________________________________ ■ ■
7.  Do you have any of the following? Asthma, Hay Fever, Food Allergies, Metal or Latex Allergies, Skin Rashes, Hives,
or any other allergic conditions? ________________________________________________________________________________________________ ■ ■
8.  Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? _____________ ■ ■ If so, please explain: ___________________________________________________________________________________________________________
9.  Have you been advised by your Medical Doctor or Dentist to take antibiotics prior to dental treatment? ___________________________ ■ ■
10. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily? _____________________________________________________________ ■ ■
11. Do your ankles, feet or hands swell? ____________________________________________________________________________________________ ■ ■
12. Are you thirsty much of the time or urinate more than 6 times per day? __________________________________________________________ ■ ■
13. Has your weight, appetite or energy level changed dramatically recently? ________________________________________________________ ■ ■
14. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?_______________________________________ ■ ■
15. Do you have FREQuENT SEVERE headaches, earaches, ear/throat infections? _________________________________________________ ■ ■
16. Have you ever had any injury or surgery to your face or jaws? ___________________________________________________________________ ■ ■
17. Have you had any other surgeries?______________________________________________________________________________________________ ■ ■
18. Do you smoke or use any other forms of tobacco?_______________________________________________________________________________ ■ ■
19. Are you alcohol and/or drug dependent?________________________________________________________________________________________ ■ ■
and have you received treatment?_______________________________________________________________________________________________ ■ ■
20. Do you have hearing difficulties? _______________________________________________________________________________________________ ■ ■
21. Are you taking or have you ever taken BISPHOSPHONATE drugs such as Fosomax, Skelid, Actonel (for osteoporosis) or
Aredia, Zameta, or Didronel (for cancer treatments) _____________________________________________________________________________ ■ ■
22. INDICATE WHICH OF THE FOLLOWING YOu PRESENTLY HAVE OR EVER HAD: yEs No yEs No
Anemia ■ ■ Heart murmur ■ ■ Malignant Hyperthermia ■ ■Angina pectoris ■ ■ Heart pacemaker ■ ■ Mitral valve prolapse ■ ■Arthritis/rheumatism ■ ■ Heart rhythm disorder ■ ■ Organ transplant /medical implant ■ ■Artificial heart valve ■ ■ Heart surgery ■ ■ Parkinsons Disease ■ ■Artificial joints (hip, knee) ■ ■ Hepatitis A ■ ■ Psychiatric treatment ■ ■Blood disorders ■ ■ Hepatitis B ■ ■ Radiation treatment /chemotherapy ■ ■Bronchitis ■ ■ Hepatitis C ■ ■ Rheumatic /Scarlet fever ■ ■Cancer ■ ■ Herpes ■ ■ Sickle cell disease ■ ■Circulation problems ■ ■ HIV / AIDS ■ ■ Sinus trouble ■ ■Congenital heart lesions ■ ■ High/Low blood pressure ■ ■ STD’s/STI’s ■ ■Cortisone/steroids ■ ■ Hodgkins disease ■ ■ Stomach/intestinal problems ■ ■Diabetes ■ ■ Hyper (Hypo) Glycemia ■ ■ Stroke ■ ■Emphysema ■ ■ Hypertension ■ ■ Thyroid disease ■ ■Epilepsy or seizures ■ ■ Jaundice ■ ■ Tuberculosis ■ ■ 0 Fainting or dizzy spells ■ ■ Kidney disease ■ ■ ulcers 505 Glandular disorders ■ ■ Latex allergy ■ ■ Other ____________________________ ■ ■ #rm Glaucoma ■ ■ Liver disease ■ ■ Other ____________________________ ■ ■ oF Head/neck injuries ■ ■ Lung disease ■ ■ Other ____________________________ ■ ■ 482 Heart disease or attack ■ ■ Lupus ■ ■ Other ____________________________ ■ ■ -2
0
8 23. Is there a family history of any of the above conditions? _________________________________________________________________________ ■ ■
24. WOMEN ONLY: Are you pregnant or suspect you may be? ________________________________________________________ ■ ■
Are you breastfeeding? _____________________________________________________________________________________ ■ ■ 25. Are you taking birth control pills?______________________________________________________________________________________________ ■ ■
26. Do you currently have, or have you had in the past, any disease, condition or problem not listed above? _____________________ ■ ■
27. Is there anything else about your health we should be made aware of? ________________________________________________ ■ ■
MEdIcAl hIsTory

Source: http://www.anchordentalgroup.com/files/Anchor_Dental_5049_5050.pdf