Menu
Home About Us
New Patient Form Reviews Gallery Contact Us
David Gouett Dentistry

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Email: reception@davidgouettdentistry.com

Dental History

Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.

General Health Assessment

1. Are you having pain or discomfort at this time?
2. Do you feel very nervous about having dental treatment?
3. Have you ever had a bad experience in the dental office?
4. Have you been a patient in the hospital during the past two years?
5. Have you been under the care of a medical doctor in the past two years?
6. Have you taken any medicine or drugs during the past two years?
7. Are you allergic to (itching, rash, swelling of hands, feet or eYes) or made sick by penicillin, aspirin, codeine, or any other drug or medication?
8. Have you ever had any excessive bleeding requiring special treatment?

PLEASE CIRCLE ANY OF THE FOLLOWING, WHICH YOU HAVE HAD OR HAVE AT PRESENT:

Physical Wellness Indicators

9. When you walk up stairs or take a walk do you ever have to stop because of pain in our chest, shortness of breath or because you are very tired?
10. Do your ankles swell during the day?
11. Do you use more than 2 pillows to sleep?
12. Have you lost or gained more than 10 pounds in the past year?
13. Do you ever wake up from sleep short of breath?
14. Are you on a special diet?
15. Has you medical doctor ever said you have cancer or a tumor?
16. Do you have any disease, condition or problem not listed?

WOMEN ONLY

Are you pregnant?
Do you anticipate becoming pregnant?
Are you experiencing any dental problems?

Medical History Questions

1. Have you been seeing a dentist regularly?
2. Are there any growths or sore spots in your mouth?
3. Have you noticed any loose teeth, or have any of your teeth shifted?
4. Does food get caught between your teeth?
5. Are any of your teeth sensitive to heat, cold, sweets or pressure?
6. Have you been advised to take antibiotics before a dental appointment?
7. Do you use dental floss, proxabrush, or stimudents?
8. How often do you brush your teeth?
- Do you feel that you have bad breath?
9. Have you ever had one of the following?
- Periodontal treatment? (treatment of the gums)
- Orthodontic treatment? (to straighten or realign teeth)
- A bite plate or any other appliance?
- Your bite adjusted or teeth ground?
- Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?)
10. JAW PROBLEMS - Do you have any of the following?
- Popping/clicking in your jaw joints?
- Pain in your jaw joints, around your ear, or side of your face?
- Difficulty in opening or closing?
- Pain when teeth are clenched?
- Pain/difficulty in chewing?
11. Do you have any of the following habits?
- Clenching or grinding your teeth while awake or asleep?
- Biting your cheeks or lips regularly?
- Breathing through your mouth while awake or asleep?
- Hold foreign objects with your teeth (pencils, nails, pipes, pins, fingernails)?
12. Do you have any emotional concerns about having dental treatment?
13. Are you happy with the appearance of your teeth?
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?

FINANCIAL AGREEMENT

Payment must be made the day of surgery. Our office will electronically file dental claims on your behalf if you have dental insurance.

Please provide us the appropriate insurance information:

A Charge of 200.00 for less than 48 hours' notice of cancellation appointment.

1

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. Ontario has a law that protects personal health information. Dr. David Gouett and Associates maintain a strict privacy policy (for more information please ask to see the Privacy Policy). I agree that Dr. David Gouett and Associates can collect, use and disclose personal information in accordance with the privacy legislation set forth by the Province of Ontario. I give Dr. David Gouett and Associates permission to sent my dental claims electronically and confirm appointments or send referrals via email.

2

I assume all responsibility for fees associated with my dental treatment. Please note: A potential fee may be charged for any missed or rescheduled appointments without 2 full business days notice.

3

I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to David Gouett Dentistry. This authorization shall continue in effect until the undersigned revokes the same.