David Gouett Dentistry ADDRESS:
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.

1. PATIENT INFORMATION
Full Legal Name [Patient Full Name]
Street Address [Street Address]
City [City] Postal Code [Postal Code]
Date of Birth [MM/DD/YYYY] Home Phone [Home Phone]
Cell Phone [Cell Phone] Health Card # [Health Card Number]
GENERAL HEALTH ASSESSMENT
1. Are you having pain or discomfort at this time?
RESPONSE: [Yes / No]
2. Do you feel very nervous about having dental treatment?
RESPONSE: [Yes / No]
3. Have you ever had a bad experience in the dental office?
RESPONSE: [Yes / No]
4. Have you been a patient in the hospital during the past two years?
RESPONSE: [Yes / No]
5. Have you been under the care of a medical doctor in the past two years?
RESPONSE: [Yes / No]
6. Have you taken any medicine or drugs during the past two years?
RESPONSE: [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?
RESPONSE: [Yes / No]
If yes, please list: [List of Allergies]
8. Have you ever had any excessive bleeding requiring special treatment?
RESPONSE: [Yes / No]
PLEASE CIRCLE ANY OF THE FOLLOWING, WHICH YOU HAVE HAD OR HAVE AT PRESENT:
[Heart Failure], [Heart Disease/Attack], [Hay Fever], [Tuberculosis], [Heart Murmur], [Sinus Trouble], [Allergies/hives], [Thyroid Disease], [X-ray cobalt tmt], [Arthritis], [Artificial Joint], [Rheumatism], [Cortisone medicine], [Glaucoma], [Pain in Jaw Joints], [Emphysema], [Cough], [Angina Pectoris], [Asthma], [Yellow Jaundice], [Blood transfusion], [Drug addiction], [Cold sores], [Genital Herpes], [Chemotherapy], [Anemia], [Nervousness], [Psychiatric Tmt], [Sickle Cell Disease], [Aids], [Hep A B C], [High blood pressure], [Liver Disease], [Rheumatic Fever], [Congenital Heart lesions], [artificial heart valve], [Pacemaker], [Heart surgery], [Epilepsy/seizures], [Fainting/Dizziness], [Stroke], [Kidney Trouble], [Ulcers]
SELECTED CONDITIONS:
  • • [Selected Condition 1]
  • • [Selected Condition 2]
  • • [Selected Condition 3]
  • [Patient's Selected Conditions List]
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?
RESPONSE: [Yes / No]
10. Do your ankles swell during the day?
RESPONSE: [Yes / No]
11. Do you use more than 2 pillows to sleep?
RESPONSE: [Yes / No]
12. Have you lost or gained more than 10 pounds in the past year?
RESPONSE: [Yes / No]
13. Do you ever wake up from sleep short of breath?
RESPONSE: [Yes / No]
14. Are you on a special diet?
RESPONSE: [Yes / No]
15. Has you medical doctor ever said you have cancer or a tumor?
RESPONSE: [Yes / No]
16. Do you have any disease, condition or problem not listed?
RESPONSE: [Yes / No]
If yes, please explain: [Explanation]
WOMEN ONLY
Are you pregnant?
RESPONSE: [Yes / No]
Do you anticipate becoming pregnant?
RESPONSE: [Yes / No]
DENTAL PROBLEMS / HISTORY
Are you experiencing any dental problems?
RESPONSE: [Yes / No]
Date of last dental visit: [MM/DD/YYYY]
Dental cleaning frequency: [Response]
When were X-rays taken last? [Month / Year]
MEDICAL HISTORY QUESTIONS
1. Have you been seeing a dentist regularly?
RESPONSE: [Yes / No]
2. Are there any growths or sore spots in your mouth?
RESPONSE: [Yes / No]
3. Have you noticed any loose teeth, or have any of your teeth shifted?
RESPONSE: [Yes / No]
4. Does food get caught between your teeth?
RESPONSE: [Yes / No]
5. Are any of your teeth sensitive to heat, cold, sweets or pressure?
RESPONSE: [Yes / No]
6. Have you been advised to take antibiotics before a dental appointment?
RESPONSE: [Yes / No]
7. Do you use dental floss, proxabrush, or stimudents?
RESPONSE: [Yes / No]
How often: [Response]
8. How often do you brush your teeth? [Response]
- Do you feel that you have bad breath?
RESPONSE: [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? (jaw joint, implant surgery etc): [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, ear, or side of 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?: [Yes / No]
• Biting your cheeks or lips regularly?: [Yes / No]
• Breathing through your mouth?: [Yes / No]
• Hold foreign objects with your teeth?: [Yes / No]
12. Do you have any emotional concerns about having dental treatment?
RESPONSE: [Yes / No]
13. Are you happy with the appearance of your teeth?
RESPONSE: [Yes / No]
If no, what would you like to see changed: [Response]
14. Have you ever had an upsetting experience in a dental office?
RESPONSE: [Yes / No]
Please describe if yes: [Response]
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.

POLICY HOLDER NAME & DOB: [Name and DOB]
INS. COMPANY: [Insurance Company]
POLICY/CONTRACT #: [Number]
CERTIFICATE: [Certificate Number]

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.
CONSENT: [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.
CONSENT: [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
[Patient Signature Placeholder]
Date of Signature
[MM/DD/YYYY]
David Gouett Dentistry

© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.