Confidential Patient Questionnaire (Coxwell)

Welcome to D on D Dental - Coxwell office

It is important to be thorough and list all your information to ensure that any options we discuss are
appropriate for your unique situation. All information is strictly confidential

Name *

First

Last

DATE OF BIRTH *

DD/MM/YY

SEX

M / F

HOME PHONE

WORK PHONE

CELL PHONE

PREFERRED CONTACT *

HOME PHONE
WORK PHONE
CELL PHONE

MAILING ADDRESS *

CITY *

PROVINCE *

POSTAL CODE *

Email *

EMPLOYER

PERSON RESPONSIBLE FOR ACCOUNT

RELATIONSHIP

EMERGENCY CONTACT

RELATIONSHIP

PHONE NUMBER

HOW DID YOU HEAR ABOUT OUR OFFICE?

DENTAL INSURANCE COMPANY

GROUP/ POLICY NUMBER

CONTRACT/ ID NUMBER

MEDICAL HISTORY

1. Are you presently in good health? *

2. Are you presently under the care of a physician? *

If so, please explain:

3. Family physician:

Phone No:

4. Have you ever had a serious illness or operation or been hospitalized? *

If so, please explain:

5. Are you taking any medicine or drugs at the present time? *

If so, please specify:

Drug/Reason

6. Have you allergies to any drugs or medicines? *

If so, please specify:

(Example: Penicillin)

8. Is there any history of family diseases i.e. Heart problems, diabetes, etc? *

9. Have you ever had an injury, surgery or X-ray therapy on your face or jaw? *

10. Have you ever had any known contact with the AIDS or HIV virus? *

11. Have you ever had local anaesthetic (freezing)? *

Any complications? Please specify:

12. Do you smoke tobacco? *

13. Is there anything that the Doctor should know regarding your medical history that Hasn’t been mentioned? Please Specify:

Your Signature (Name) *

First

Last

Date *

DENTAL HISTORY

1. When was your last dental visit?

2. How often do you have a dental check-up? *

6 months
Yearly
Other

4. Have you ever had an unfavourable experience at the dentist? *

If so, please explain:

5. Are any of your teeth sensitive to:

Cold
Hot
Sweets
Biting

6. Does food catch between your teeth? *

If so, where?

7. Do your gums bleed when brushing or flossing? *

8. Do you suffer from pain and/ or swelling of your gums? *

9. Are you conscious of bad breath or a bad taste in your mouth? *

10. Do you favour one side when chewing? *

11. Are you unhappy with the appearance of your teeth and smile? *

If so, please explain:

12. Do you gag easily? *

13. Do you ever wake up with a headache or have a tired feeling in your face or jaw? *

14. Do your jaw joints pop, click or grind when opening widely? *

15. Do you clench or grind your teeth? *

16. Have you lost any teeth due to: abscess

Accident
Decay
Gum disease

17. Are you anxious to keep your natural teeth? *

18. Are you tense during dental visits? *

19. Do you snore at night? *

20. Do you wake up in the middle of the night? *

21. Describe in your own words, what you would like done with your teeth:

PATIENT CERTIFICATION AND CONSENT I, the undersigned, certify that all of the medical and dental information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures as agreed to be necessary or advised and I will assume responsibility for the fees associated with these procedures. *

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Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we require 48 hours notice, otherwise, it may be necessary to charge for the time lost. Our office policy is that services are paid for at each visit as they are performed.