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Patient Information
Name
*
First
Last
Date of Birth
*
DD
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MM
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YYYY
2024
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2016
2015
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2012
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2008
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2004
2003
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2000
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1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex
*
Female
Male
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Vietnam
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Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
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Zambia
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Åland Islands
Country
Put 00000 in Postal Code if none.
Office Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Put 00000 in Postal Code if none.
Home Tel
Office Tel
Mobile
*
Email
*
HKID #
Referred By
Occupation
Nationality
Emergency Contact
*
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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?
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
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MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date of most recent x-rays?
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date of most recent treatment (not cleaning)?
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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?
No
Yes
Have you ever had complications from past dental treatments?
No
Yes
Have you ever had trouble getting numb or reactions to local anesthetic?
No
Yes
Did you ever have braces, orthodontic treatment or had your bite adjusted?
No
Yes
Have you had any teeth removed?
No
Yes
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?
No
Yes
Have you ever whitened (bleached) your teeth?
No
Yes
Are you embarrassed about your smile?
No
Yes
Have you been disappointed with the appearance of previous dental work?
No
Yes
Bite and Jaw Joint
Do you have any problems chewing gum?
No
Yes
Do you have any problems chewing bagels or other hard food?
No
Yes
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
No
Yes
Are your teeth crowding or developing spaces?
No
Yes
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
No
Yes
Do you have any problems with sleep or wake up with an awareness of your teeth?
No
Yes
Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
No
Yes
Do you have tension headaches or sore teeth?
No
Yes
Do you wear or have you worn a bite appliance?
No
Yes
Tooth structure
Have you had any cavities within the past 3 years?
No
Yes
Do you have a dry mouth?
No
Yes
Are any teeth sensitive to hot, cold, biting or sweets?
No
Yes
Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
No
Yes
Do you avoid brushing any part of your mouth?
No
Yes
Gum and Bone
Have you ever been diagnosed or treated for periodontal (gum) disease?
No
Yes
Have you ever experienced gum recession?
No
Yes
Is there anyone with a history of periodontal disease in your family?
No
Yes
Do your gums bleed when brushing, flossing or eating?
No
Yes
Are your teeth becoming loose?
No
Yes
Have you ever noticed an unpleasant taste or odor in your mouth?
No
Yes
Have you experienced a burning sensation in your mouth?
No
Yes
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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
Yes
No
Aware of a change in your health
Yes
No
On weight management medication
Yes
No
Taking dietary supplements
Yes
No
Often exhausted or fatigued
Yes
No
Subject to frequent headaches
Yes
No
A smoker or smoked previously
Yes
No
FEMALE - taking birth control pills
Yes
No
FEMALE - pregnant
Yes
No
MALE - prostate disorders
Yes
No
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.
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