New Patient Medical History Form Dr. Dima Oweis B.Sc D.D.S. General Family Dentistry

Providing Aspen Dental Care with the information requested below enables us to deliver you with the best possible dental care. All information is strictly confidential and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand.

This form is fillable; please complete it on your computer and email it back to us. It will be ready for you to sign at your first appointment. To get to the next fillable field, please click the ‘tab’ button.

First Name: Last Name: Date Of Birth (DD/MM/YYYY) Occupation: Phone Home#: Cell#: Work#: E-MAIL:

Home/Billing Address:

Number Street Quadrant

City Province Postal Code

In case of emergency please notify: Name: Phone: Relationship:

REFERRAL INFORMATION

Internet/Website Walk/ Drive-By Yellow Pages Dentist/Dr.

Patient (please provide name so we can thank them)

MEDICAL HISTORY

Family Doctor: Doctor’s Phone #: Doctor’s Address: When was your last medical check-up?

Have you ever had any of the following? Please circle Y= yes or N= no Anaemia Y N Epilepsy Y N Liver Disease Y N Steroid Therapy Y N

Artificial Joints Y N Excessive Bleeding Y N HIV/AIDS Y N Stomach Ulcers Y N

Asthma Y N Fainting Y N Jaundice Y N Tuberculosis Y N

Blood Disease Y N Glaucoma Y N Pacemaker Y N Tumors Y N

Cancer Y N Heart Disease Y N Psychological Disorders Y N Others?

Chest Pain-Angina Y N Heart Murmur Y N Radiation Therapy Y N

Diabetes Y N Hepatitis A,B, C Y N Respiratory Problems Y N

of 2 Diet Pill Therapy Y N Blood Pressure Y N Rheumatic Problems Y N

Dizziness Y N Kidney Disease Y N Sinus Problems Y N

1. Are you presently being treated for any medical conditions OR have been within the past year?

YES NO if yes, please explain here:

2. Are you currently taking any medications? YES NO If yes please list here :

3. Are you currently taking any vitamins or herbal supplements? YES NO If yes, please list here:

4. Do you have any allergies? YES NO

If Yes, Please list here (Include ANY/ALL allergies to medications, Latex/Rubber products or any food):

5. Do you currently smoke or chew tobacco? YES NO

If yes, how many/much per day?

6. Have you ever smoked or chewed tobacco in the past? YES NO

7. Have you ever had a peculiar or adverse reaction to any medication or injections? YES NO

If yes, please explain here:

WOMAN ONLY:

Are you pregnant? YES NO If yes, how many months?

Breast-feeding? YES NO

OFFICE USE ONLY (clinic notes):______

DENTAL HISTORY

 Are you concerned about or experiencing any of the following dental problems?(Please all that apply)

Sensitivity to hot or cold Staining of your teeth/ yellow teeth Ability to eat

Bleeding gums grinding or clenching of your teeth Missing teeth

Head/Neck Ache Clicking/Pain in the jaw joints Roughness of existing fillings

Food trapping between Existing Crowns, bridges or dentures Sensitivity when eating

Discolored Fillings Problems with previous dental treatment Bad Breath

Crooked Teeth/ Gaps between your teeth

of 2  What is the main purpose of your visit today?  When was your last dental visit?  Are you happy with the color of your teeth? YES NO

 Have you ever been advised by your doctor to take antibiotics before dental treatment? YES NO

 Are your teeth sensitive during dental cleanings? Very Sensitive Mildly Sensitive No Sensitivity

 Does dental treatment make you nervous? No Slightly Moderately Extremely

To the best of my knowledge, the above information is correct

Patient Signature ______(Parent of guardian must sign if patient is under 18 years of age)

Date: ______