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

# 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.

Name:
Address:
City:
Postal Code:
DATE OF BIRTH:
Home #:
Cell #:
HEALTH CARD NUMBER:

## 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

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

Heart Failure Emphysema Aids Heart Disease/Attack Cough Hep A B C Hay Fever Angina Pectoris High blood pressure Tuberculosis Asthma Liver Disease Heart Murmur Yellow Jaundice Rheumatic Fever Sinus Trouble Blood transfusion Congenital Heart lesions Allergies/hives Drug addiction artificial heart valve Thyroid disease Cold sores Pacemaker X-ray cobalt tmt Genital herpes Heart surgery Arthritis Chemotherapy Epilepsy/seizures Artificial Joint Anemia Fainting/Dizziness Rheumatism Nervousness Stroke Cortisone medicine Psychiatric Tmt Kidney Trouble Glaucoma Sickle Cell Disease Ulcers Pain in Jaw Joints

## 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:

### WOMEN ONLY

Are you pregnant?
Yes No
Do you anticipate becoming pregnant?
Yes No
Are you experiencing any dental problems?
Yes No
Date of your last dental visit:
Dental cleaning:
When were X-rays taken last?

## Medical History Questions

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.

Please provide us the appropriate insurance information:

Policy Holder's Name and Date of Birth:
Ins. Company:
Policy/Contract #:
Certificate:

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