New Patient Form – Crown Dental Studio

Patient Information

Name *

First

Last

Date of Birth *//

Sex *

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Put 00000 in Postal Code if none.

Office Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Put 00000 in Postal Code if none.

Home Tel

Office Tel

Mobile *

Email *

HKID #

Referred By

Occupation

Nationality

Emergency Contact *

Dental History

Referred by

How would you rate the condition of your mouth:

Excellent
Good
Fair
Poor

Previous Dentist

How long have you been a patient?

Date of most recent dental exam?//

Date of most recent x-rays? //

Date of most recent treatment (not cleaning)?//

I routinely see my dentist every

3 Months
4 Months
6 Months
12 Months
Not routinely

What is your immediate dental concern

Personal History

How fearful are you of dental treatment?

(1 to 10, 10 = very)

Have you had an unfavorable dental experience?

Have you ever had complications from past dental treatments?

Have you ever had trouble getting numb or reactions to local anesthetic?

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Have you had any teeth removed?

Smile Characteristics

How happy are you with the appearance of your teeth?

(1 to 10, 10 = very)

Is there anything about the appearance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Are you embarrassed about your smile?

Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint

Do you have any problems chewing gum?

Do you have any problems chewing bagels or other hard food?

Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Are your teeth crowding or developing spaces?

Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?

Do you have any problems with sleep or wake up with an awareness of your teeth?

Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Do you have tension headaches or sore teeth?

Do you wear or have you worn a bite appliance?

Tooth structure

Have you had any cavities within the past 3 years?

Do you have a dry mouth?

Are any teeth sensitive to hot, cold, biting or sweets?

Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?

Do you avoid brushing any part of your mouth?

Gum and Bone

Have you ever been diagnosed or treated for periodontal (gum) disease?

Have you ever experienced gum recession?

Is there anyone with a history of periodontal disease in your family?

Do your gums bleed when brushing, flossing or eating?

Are your teeth becoming loose?

Have you ever noticed an unpleasant taste or odor in your mouth?

Have you experienced a burning sensation in your mouth?

Medical History

Name of Physician and their specialty

Most recent physical examination and purpose

What is your estimate of your general health

Poor
Fair
Good

Do you have, or have you ever had:

Heart problems
Stomach or duodenal ulcer
Heart murmur
Digestive disorders (i.e. gastric reflux)
Rheumatic fever
Osteoporosis/osteoperia
Scarlet fever
Arthritis
High blood pressure
Glaucoma
Low blood pressure
Contact lens
A stroke
Head or neck injuries
Artificial prosthesis (i.e. heart valve of joints)
Epilepsy, convulsions (seizures)
Anemia or other blood disorder
Neurological problems
A smoker or used to smoke
Viral infections and cold sores
Emphysema
Any lumps or swelling in the mouth
Tuberculosis
Hives, skin rash, hay fever
Asthma
Venereal disease
Diabetes
Hepatitis (type: )
Kidney disease
HIV/AIDS
Liver disease
Tumor, abnormal growth
Jaundice
Radiation therapy
Thyroid or parathyroid disease
Chemotherapy
Hormone deficiency
Antidepressant medication
High cholesterol
Hospitalization for illness or injury
Breathing or sleep problems (i.e. snoring, sinus)

Do you have any allergic reaction to:

Aspirin, Ibuprofen, Paracetamol
Penicillin
Erythromycin
Tetracycline
Codeine
Local anesthetic
Fluoride
Metals (gold, stainless steel)
Latex
Other

If other, please state below:

Are you:

Presently being treated for any illness

Aware of a change in your health

On weight management medication

Taking dietary supplements

Often exhausted or fatigued

Subject to frequent headaches

A smoker or smoked previously

FEMALE - taking birth control pills

FEMALE - pregnant

MALE - prostate disorders

Describe any urgent medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment:

List all medication, supplements and/or vitamins taken within the last two years:

Signature (type your full name): *

By signing this form, you certify that all information is true and correct to the best of your knowledge.