location_on 805 Development Dr ❘ Kingston, Ontario K7M 4W6
call(613) 389-8660
mail reception@davidgouettdentistry.com

805 Development Dr, Kingston, ON K7M 4W6

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

# New Patient Form

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

## 1 REGISTRATION INFORMATION

The patient is an: Adult Child Adult under guardianship
Name of Guardian
First Name
Last Name
Dr. Mr. Mrs. Ms. Miss.
Prefers To Be Called
Employer
Address: Street
Address 2: Street
City and Prov/State
Zip/Postal code
Reason for today's visit?
Examination Emergency Other
Is there a dental problem you would like treated immediately?
Home Phone
Cell Phone
Bus. Phone
E-mail address
May we call you at work?
Yes No
Prefers to be called
Occupation
Date of Birth (M/D/Y)
Age
Gender and Pronuns
Marital Status
Name of Spouse
Health Card Number
Are other family members patients at our office?
Yes
Whom may we thank for referring you?
Family Physician
Phone
Medical Specialist (if presently under care)
Phone
In case of emergency, please contact
Phone

## 2 FINANCIAL & CREDIT INFORMATION

Person responsible for account: Self Spouse Other
Name: Last, First
Home Phone
Driver's Lic. No.
Health Card #
Credit Card No.
Expiry Date

### Primary Dental Insurance

Subscriber's name
D.O.B.
Ins. yr. end
Emp./Grp. policy holder
Ins. Co.
Tel.
Grp./Ind. policy No.
Cert. No.

### Secondary Dental Insurance

Subscriber's name
D.O.B.
Ins. yr. end
Emp./Grp. policy holder
Ins. Co.
Tel.
Grp./Ind. policy No.
Cert. No.

## 3 MEDICAL HISTORY QUESTIONS

1. Are you being treated for any medical condition at the present or have you been treated within the last year?

Yes No

2. Has there been any change in your general health in the past year?

Yes No
3. When was your last medical checkup?

4. Do you have any conditions that could affect your immune system? (e.g. Leukemia, HIV +/- tested, Lupus)

Yes No

5. Are you undergoing any therapies that could affect your immune system? (e.g. Radiotherapy or Chemotherapy)

Yes No

6. Are you currently taking any steroids or cortisone?

Yes No

7. Do your ankles, feet or hands swell?

Yes No

8. Are you allergic to any medications?

Yes No
If yes, please list:

9. Are you allergic to any of the following?

Latex Metal Rubber None of the above Not Sure

10. Are you allergic to any foods?

Yes No
If yes, please list:

11. Do you have any other allergies that we should be aware of?

Yes No
If yes, please list:

12. Have you ever had any peculiar or adverse reactions to any medicines or injections?

Yes No
If yes, please list:

13. Are you taking or have you ever taken osteoporosis medications? (e.g. Fosamax, Actonel)

I am currently taking I was previously taking but am no longer No
If currently or previously taking, please specify which medication:

14. Are you currently taking any prescription medications?

Yes No
If yes, please list:

15. Do you take any recreational drugs on a regular basis?

Yes No
If yes, please list:

16. Are you taking any herbal supplements of any kind?

Yes No
If yes, please list:

17. Do you have diabetes?

I have Type 1 Diabetes I have Type 2 Diabetes No

18. Do you have or have you ever had any of the following?

Arthritis/Rheumatism Asthma Cancer Chest Pain/Angina Crohn's Disease Drug/Alcohol Dependency Fainting or Dizzy Spells Glaucoma Hay Fever Head/Neck Injuries Heart Attack Hepatitis A Hepatitis B Hepatitis C Herpes - Oral/HSV-1 Hyperglycemia Hypoglycemia Jaundice Kidney Disease Liver Disease Lung Disease/Emphysema Malignant Hyperthermia Mitral Valve Prolapse Pacemaker Psychiatric/Mental Disorders Rheumatic/Scarlet Fever Seizures (Epilepsy) Shortness of Breath Sickle Cell Disease Sinus Trouble Stomach Ulcers Hay Stroke Thyroid Disease Tuberculosis

19. Do you have or have you had any conditions or diseases not previously listed that we should be aware of?

Yes No
If yes, please list:

20. Are there any diseases or medical problems that run in your family?

Cancer Heart Disease Diabetes Malignant Hyperthermia
Other

21. Do you have a bleeding problem or bleeding disorder?

Yes No

22. Do you have or have you ever had a replacement or repair of a heart valve or stent?

Yes No

23. Do you have or have you ever had an infection of the heart? (e.g. Infective Endocarditis)

Yes No

24. Have you had a transplant (heart, lungs, organs)?

Yes No

25. Do you have a heart condition from birth? (e.g. congenital heart disease/lesions)

Yes No

26. Do you have or have you ever had any heart or blood pressure problems?

Yes No

27. Do you have a prosthetic or artificial joint?

Yes No

28. Have you ever been hospitalized for any illnesses or operations?

Yes No

29. Have you ever had any injury or surgery to your face or jaws?

Yes No

30. Do you smoke or chew tobacco products?

Yes No

31. Are you nervous during dental treatment?

Yes No

32. Is there anything else about your health that we should be made aware of?

Yes No
If yes, please provide very brief details:

33. Do you wish to speak to the doctor privately about any problem or medical condition?

Yes No

34. Has the child patient recently had any of the following?

Chicken Pox Measles Mumps Chest Strep Throat Tonsilitis None/None Applicable

### WOMEN ONLY

35. Are you breastfeeding?
Yes No
36. Are you pregnant?
Yes No

## General Health Assessment

1. Are you having pain or discomfort at this time?
Yes No
2. Do you feel very nervous about having dental treatment?
Yes No
3. Have you ever had a bad experience in the dental office?
Yes No
4. Have you been a patient in the hospital during the past two years?
Yes No
5. Have you been under the care of a medical doctor in the past two years?
Yes No
6. Have you taken any medicine or drugs during the past two years?
Yes No
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?
Yes No
If Yes, please list
8. Have you ever had any excessive bleeding requiring special treatment?
Yes No

## 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?
Yes No
10. Do your ankles swell during the day?
Yes No
11. Do you use more than 2 pillows to sleep?
Yes No
12. Have you lost or gained more than 10 pounds in the past year?
Yes No
13. Do you ever wake up from sleep short of breath?
Yes No
14. Are you on a special diet?
Yes No
15. Has you medical doctor ever said you have cancer or a tumor?
Yes No
16. Do you have any disease, condition or problem not listed?
Yes No
If Yes, please explain:

# Dental History

Are you experiencing any dental problems?
Yes No
Date of your last dental visit:
Dental cleaning:
When were X-rays taken last?
1. Have you been seeing a dentist regularly?
Yes No
2. Are there any growths or sore spots in your mouth?
Yes No
3. Have you noticed any loose teeth, or have any of your teeth shifted?
Yes No
4. Does food get caught between your teeth?
Yes No
5. Are any of your teeth sensitive to heat, cold, sweets or pressure?
Yes No
6. Have you been advised to take antibiotics before a dental appointment?
Yes No
7. Do you use dental floss, proxabrush, or stimudents?
Yes No
How often?
8. How often do you brush your teeth?
- Do you feel that you have bad breath?
Yes No
9. Have you ever had one of the following?
- Periodontal treatment? (treatment of the gums)
Yes No
- Orthodontic treatment? (to straighten or realign teeth)
Yes No
- A bite plate or any other appliance?
Yes No
- Your bite adjusted or teeth ground?
Yes No
- Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?)
Yes No
10. JAW PROBLEMS - Do you have any of the following?
- Popping/clicking in your jaw joints?
Yes No
- Pain in your jaw joints, around your ear, or side of your face?
Yes No
- Difficulty in opening or closing?
Yes No
- Pain when teeth are clenched?
Yes No
- Pain/difficulty in chewing?
Yes No
11. Do you have any of the following habits?
- Clenching or grinding your teeth while awake or asleep?
Yes No
- Biting your cheeks or lips regularly?
Yes No
- Breathing through your mouth while awake or asleep?
Yes No
- Hold foreign objects with your teeth (pencils, nails, pipes, pins, fingernails)?
Yes No
12. Do you have any emotional concerns about having dental treatment?
Yes No
13. Are you happy with the appearance of your teeth?
Yes No
If no, what would you like to see changed?
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?
Yes No

### 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.

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.

YES NO
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.

YES
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.

Patient/Guardian Signature
Date of Signature