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David Gouett Dentistry

Address

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Fax: 613-389-9003

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.

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?
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.