Thank You - Chatterton Way Dental

Contact Info

Name*

First Last

Date of Birth*

YYYY slash MM slash DD

Home Phone*

Cell Phone

Email Address*

Emergency Contact*

First Last

Emergency Contact Phone*

Address*

Street Address Address Line 2 City Province Postal Code

Employer*

Occupation*

Who can we thank for referring you to us?

Health History

Who is your current personal family physician?*

Are you being treated for any medical condition at the present or have you been treated within the last year? If so, why?*

When was your last medical check-up?*

Have you ever been hospitalized for any illness or operations?*

Are you currently taking any medications, non-prescription drugs or herbal supplements?*

Do you have any allergies?*

Have you ever had any peculiar or adverse reactions or injections?*

Have you ever*

Fainted?

Experienced shortness of breath?

Experienced chest pain?

Had injury/surgery/radiation therapy to your face? Jaw? Head or neck?

Had a general anesthetic?

Do you get frequent migraines/headaches?

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

Had a replacement or repair of a heart valve, and infection of the heart, heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Do you have a prosthetic or artificial joint?

Do you have a bleeding problem or bleeding disorder?

None of these.

Have you ever been diagnosed with*

Alzheimers

Anemia

Angina

Arthritis

Cancer

Diabetes (Type 1 or 2)

Drug/Alcohol Dependency

Emphysema

Epilepsy/Seizures

Fibromyalgia

Heart Attack

Hodgkins Disease

Hypo/hyperglycemia

Lupus

Kidney Disease

Lung Disease

Parkinsons Disease

Rheumatic Fever

Sexual Transmitted Infection

Steroid Therapy

Stomach Ulcers

Stroke

Thyroid Disorder

Tuberculosis

None of these

Are there any conditions or disease not listed above that you have or have had?*

Yes

Please list*

Are there any diseases or medical conditions that run in your family (i.e. diabetes, cancer, heart disease)?*

Yes

Please list*

Do you smoke or chew tobacco products?*

Yes

Dental History

When was your last dental visit?*

Who is your previous dentist?*

When did you last have dental x-rays taken?*

Have you ever been advised to take antibiotics before dental appointments?*

Have your tooth/teeth ache lately? If so, for how long?*

Are your teeth sensitive? If so, in which area(s)?*

Do you gums bleed when you brush or floss your teeth?*

Do you have any pain when you chew?*

Do you feel you have bad breath?*

Have you ever been in a vehicle accident or experienced any blows to your jaw?*

Have you ever had any implant surgery in your jaw or either jaw joints? If so, who performed the surgery and when was it done?*

Are you being followed-up by a dental specialist?*

Please list anything not mentioned above regarding your past dental history?*

Do you have dental insurance?*

Yes

The information I provided above is true to the best of my knowledge, and I will assume responsibility for fees associated with any dental procedures completed at Dr. M. Foulkes’ dental office.*

Yes, what I've stated here is true to my knowledge.

Thank you for contacting Chatterton Way Dental. We will receive your email shortly and will be in touch.

Are you a new patient, or an existing client who hasn’t been in for a visit in over three years?

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Health History

Dental History

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