NEW PATIENT INFORMATION FORM Do you have a fever, difficulty breathing or a cough?* Have you returned from travel in the last 14 days?* Have you been in contact with a suspected or confirmed case of COVID-19?* Are you experiencing pain or discomfort?* PERSONAL INFORMATION Name First NameLast Name Date of Birth January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Sex Please Select Male Female N/A Contact Number: E-mail example@example.com Address: Street Address Street Address Line 2 CityState / Province Postal / Zip Code Marital Status Please Select Single Married Divorced Legally separated Widowed In case of emergency Emergency Contact: First NameLast Name Relationship Contact Number Date of Last Visit: How did you hear about us? INSURANCE INFORMATION (IF APPLICABLE) Do you have Insurance Coverage: YesNo MEDICAL HISTORY AND DETAILS Have you been hospitalized or had a major operation within the last 2 years? YesNo If you indicated “Yes”, please provide details: Are you or could you be pregnant and/or breastfeeding? YesNo If you indicated “Yes”, please provide details: Do you have, or have you ever had, a heart condition or tested positive for a disease that could affect your immune system? (e.g. leukemia requiring chemotherapy) YesNo If you indicated “Yes”, please provide details: Please indicate which of the following you have had or have ever had: AIDS/HIV Positive YESNO Alzheimer’s Disease YESNO Anaphylaxis YESNO Anemia YESNO Arthritis/Gout YESNO Artificial Heart Valve YESNO Artificial Joint YESNO Asthma YESNO Blood Disease YESNO Bruise Easily YESNO Cancer YESNO Chest Pains YESNO Circulation Problems YESNO Diabetes YESNO Emphysema YESNO Epilepsy/Seizures YESNO Psychiatric Disorder YESNO Eating Disorder YESNO Fainting YESNO Glaucoma YESNO Gastrointestinal Disorders YESNO Head or Neck Injuries YESNO Heart Attack/Failure YESNO Heart Murmur YESNO Heart Pacemaker YESNO Heart Surgery YESNO Hemophilia YESNO Hepatitis A/B/or C YESNO High Blood Pressure YESNO Infective Endocarditis YESNO Jaundice YESNO Alcohol or Drug Dependency YESNO Liver Disease YESNO Lung Disease YESNO Mental/Nervous Disorder YESNO Organ/Medical Transplant YESNO Prosthetic Joints YESNO Sickle Cell Disease YESNO Stroke YESNO Tuberculosis YESNO Additional comments and/or medical conditions (current or otherwise) not listed: Are you currently taking any prescription or non-prescription medication? YESNO If you indicated “Yes”, please provide details: DENTAL VISITS AND DENTAL HISTORY Are you nervous during dental visits or treatment? YESNO Have you ever had complications from past dental treatment? YESNO Have you ever experienced a dental operation or procedure of any kind? YESNO Do you bruise easily or bleed severely when cut? YESNO Have you ever had any teeth removed or had teeth that never developed? YESNO Do your gums bleed or are they painful when brushing or flossing? YESNO Have you ever noticed an unpleasant taste or odor in your mouth? YESNO Do you have problems with your jaw joint? (pain, sounds, locking, popping) YESNO Are any teeth sensitive to hot or cold temperatures? YESNO Do you chew ice, bite your nails, or have any other oral habits? 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 Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? YESNO Name of Last Dentist: Date of Last Visit: ALLERGIES Local Anaesthetic YESNO If you have ever been advised against, or had a reaction to, taking any other type of medication, please list it: Please list any allergic conditions (e.g. asthma, hay fever, food allergies, latex allergy): CHILDREN UNDER THE AGE OF 18 ONLY: Please list any medical conditions the child has recently had (e.g. measles, strep throat, tonsillitis etc.) SUBMIT Should be Empty:
