Welcome to Clearbrook Dental! In order for us to provide you with the highest standard of dental care we ask that you fill out the following form.

All information is strictly confidential and will remain with this office. Our receptionist is available to assist you with the completion of this form.

Dental History

Is there a dental problem you would like treated immediately? Yes No 9ȄLJƭŀƛƴDate of your last dental visit? Last Dental Cleaning? Last x-rays?

Previous Dentist Phone #

Are you happy with the appearance of your teeth? Yes No

What would you like to see changed?

Have you ever had any of the following treatments?

Orthodontics (Braces/Invisalign) Periodontal (gum) Treatment Crowns/Bridges

Oral Surgery Extractions Root Canal

Dental Implants Full/Partial Dentures Cosmetic Treatment

Do you experience any of the following:

Bleeding gums Bad Breath Painful/Swollen gums

Food traps between teeth Tooth Sensitivity Dry mouth

Last Initial Dr. Mr. Mrs. Ms. Miss

Date of Birth Gender

Unit # City Postal Code

Cell Phone

Province

Bus. Phone Ext

Patient Information

Name: First

Prefers to be called

Address: Street

Home Phone

E-mail address

Occupation Marital Status Name of Spouse

Have we treated another member of your family? Yes No Names:

Existing patient Sign Website Ad Mailer Other

Phone

How did you hear about our office?

In case of emergency, please contact

Nearest relative not living with you Phone

Date (mm/dd/yyyy) ADULT Registration Information

Have you ever experienced the following jaw problems:

Popping/clicking in your jaw joints? Pain in your jaw joints, around your ear, or side of your face?

Difficulty in opening or closing? Jaws locked in opened or closed position?

Do you have any of the following habits?

Clenching or grinding your teeth while awake or asleep?

.ƛǘƛƴƎ ȅƻdzNJ ŎƘŜŜƪǎ ƻNJ ƭƛLJǎ?Snoring?

Mouth breathing while awake or asleep?

Have you sustained any injuries to your face mouth or chin? Yes No

Do you have any emotional concerns about having dental treatment? Yes No Explain

Have you ever had a bad experience at the dentist? Yes No Explain

Health History Are you currently being treated for any medical condition at present or within the past year?

Explain

Have there been any changes in your general health in the past year? Yes No

Last complete physical examination? When was your last visit to a Physician?

Physician Name Phone Number

List any Prescription or Non-Prescription drugs you are taking or have recently taken (including birth control pills)?

L Latex/Rubber or Metal allergies (please list)

Have you ever been seriously ill, hospitalized, or have ever had major surgery? Yes No

If yes, give details

Have you ever been advised to take antibiotics before dental treatment? Yes No

Do you have any prosthetic joints (knee, hip)? Yes No If yes, since when?

Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic

Fever? Yes No

Are you presently suffering from any infectious diseases? Yes No

Do you have any condition that could affect your immune system (e.g. arthritis, AIDS, HIV infection, lupus, inflammatory bowel

disease, Crohn’s disease)? Yes No

Have you ever had any malignant disease, or are you presently undergoing any radiation treatment/chemotherapy? Yes No

Do you bleed or bruise excessively? Yes No Do you take blood thinners? Yes No

Have you ever fainted? Yes No Do you have high blood pressure? Yes No

Are you ever short of breath? Yes No Have you ever had chest pains? Yes No

Have you gained or lost excessive weight? Yes No Are you taking diet pills? Yes No

Are you on cortisone/steroid therapy? Yes No Have you ever been Anemic? Yes No

Are you HIV positive or have AIDS? Yes No Do you have Hepatitis? Yes No

Indicate which of the following you presently have or ever had: (Please check all that apply)

Sleep Apnea Epilepsy or Seizures Tuberculosis Glandular Disorders

Asthma Hepatitis (type A,B,C) Diabetes (type I, II) Organ Transplant

Bronchitis Jaundice Kidney Disease Stomach problems

Emphysema Liver Disease Thyroid Disease Ulcers

Lung Disease Heart Attack Stroke Sinus problems

Do you have an allergy, sensitivity, or been advised against exposure to any of the following:

Antibiotics (please list)

Local Anesthetics (please list)

Pain killers (Aspirin, Codeine, NSAIDS, etc…) (please list)

Any other prescription/non-prescription drugs (please list)

Food Allergies (please list)

Environmental Allergies (please list)

Women Only: Are you pregnant? Yes No How many weeks?

Are you breastfeeding? Yes No

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

Do you or did you smoke? Yes No How much?

Do you drink alcoholic beverages on a regular basis? Yes No

Do you use recreational drugs? Yes No

General Release

I, undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical – dental history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform the examinations, diagnostic procedures and treatment as may be required. I hereby authorize release of any information related to insurance claims. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

Signature Patient Parent Guardian (please print name)

Reviewed by Treating Dentist: Date: