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Our Practice
Dr. Dean Castrisos
Dr. Lara O’Brien
Dr. Sally Hay
Dr. Quentin Wheelwright
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Treatment
Preventative Dentistry
Initial Consultation
Periodic Examination
Oral Hygiene
Fluoride Treatments
Gums – Periodontal Health
Bad Breath
Grinding Appliances
Snoring
Sports Mouthguards
Aesthetic Dentistry
Tooth Whitening
Bonding
Porcelain Veneers
Crowns
All New Lumineers!
All New Snap On Smile!
Restorative Dentistry
White Fillings – Composite
Inlays/Onlays
Crowns
Dentures
Bridge
Children’s Dentistry
Fissure Sealing
Wisdom Teeth
Root Canal (Endodontics)
Extractions
Post Operative Instructions
Local Anaesthetic/Sedation
Emergency
Gallery
Bonded Facings
Crowns
Implants
Tooth Coloured Fillings
Veneers and Lumineers
Zoom Whitening Results
Contact Us
Medical History Questionnaire Form
We would like to welcome you to our practice. To assist us in providing you with the best possible treatment and standard of care, we ask that you complete this confidential medical history questionnaire.
Name
First
Middle
Last
Date of Birth
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone: Home
Phone: Work
Cell/Mobile
Email
Drivers License Number
Work Place
Occupation
What is your preference for communication from our practice? (Please tick)
Home Phone
Work Phone
Cell/Mobile SMS
Email
Dental Fund/ Insurance Plan
Who recommended you to us
Emergency Contact
Emergency Contact Person
Phone
Have you been under the care of a medical doctor during the past two years?
Yes
No
If yes, for what?
Doctor’s Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Have you taken any medication or drugs during the past two years?
Yes
No
Are you taking any medication, drugs or pills now?
Yes
No
If yes, please list name and dosage
Are you aware of having an allergic (or adverse) reaction to any medication or substance?
Yes
No
If yes, please list
Have you been a patient in the hospital during the past five years?
Yes
No
Indicate which of the following you have had, or have at present? If yes, please tick.
Heart (surgery, disease, attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Diet (Special/Restricted)
Hepatitis
Stroke
Stomach Ulcers
Diabetes
Thyroid Problems
Glaucoma
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Troubles
HIV/AIDs
Radiation Therapy
Chemotherapy
Cold Sores/Fever Blisters
Haemophilia
Bruise easily
Liver Disease
Kidney Trouble
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Artificial Joints (hip, knee, etc.)
Tumours
Do you have or had any disease, condition or problem not listed?
Yes
No
If yes, please list
Are you:
Pregnant?
Nursing
Taking birth control pills?
Do you think you may be pregnant?
If yes, how many months
Dental History
Date of last dental visit
Last dental cleaning
Last full mouth x-rays
What was done on your last dental visit?
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
Do you have any dental problems now?
Yes
No
If yes, please describe
Are any of your teeth sensitive to:
Hot or cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odours or bad taste?
Being ground or the bite adjusted?
Do you frequently get sores, blisters or any other oral lesions?
Have you ever had:
Dental Implants?
Orthodontic Treatment?
Oral Surgery?
Periodontal or Gum Treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
Do your gums bleed or hurt
Yes
No
Have your parents experienced gum disease or tooth loss
Yes
No
Have you noticed any loose teeth or change in your bite?
Yes
No
If so, please describe, including cause?
Does food tend to become caught between your teeth?
Yes
No
If yes, where?
Are you satisfied with your teeth’s appearance?
Yes
No
Would you like to keep all of your teeth all your life?
Yes
No
Do you feel nervous about having dental treatment?
Yes
No
If so, what is your biggest concern
Have you ever had an upsetting dental experience?
Yes
No
If yes please describe
Signature
Date
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More Details
Treatments
Aesthetic Dentistry
Preventative Dentistry
Restorative Dentistry
Other Services
Root Canal (Endodontics)
Wisdom Teeth
Extractions
Post Operative Instructions