NEW PATIENT FORM - ADULT
We take pride in our exceptional patient care.
Your answers below will provide for a more personalized, comprehensive experience.
Name: ___________________________________________________
Last
First
Initial
Preferred Name: ___________________________________
Dr. Mrs.
Ms.
Miss Mr.
Birth Date: ________________ ____
Day / Month / Year
Address: _________________________________________________________________________ _
Street
City
Postal Code
Home Phone: ____________________ Work: ____________________ Cell: ________ ___________
Email: _____________________________________ Occupation: ______ ______________________
Emergency Contact Name: ___________________________ Phone Number: ____ _______________
Relationship to you: _________________________________
We offer courtesy reminders for upcoming reserved appointments. Please circle how you prefer to be
contacted (circle all that apply):
home phone
work phone
cell phone
email
Please list other members of your immediate family who are patients of our office:
__________________________________________________________________
Do you prefer to see a particular dentist, hygienist, or assistant in our office?
________
__________________________________ _______________________________________________
Can we thank someone for referring you?
________________________ ________________________________________________________
Or did you find us on your own? If so, please indicate how:
_________________
_______________________________________________________________
1
DENTAL QUESTIONNAIRE
What is your primary dental concern?
_______________________________________________________________________ __________
What do you already know about Evolution Dental, and what are your expectations?
_____________________________________________________________________ ____________
When was your last dental visit, and what treatment was done?
_______________________________________________________________ __________________
Is there any dental treatment planned?
______________________________________________________________ ___________________
Who was your previous dentist, and why did you to leave that office?
________________________ ________________________________________________________
Please tell us about your good and bad dental experience?
__________________________________________________________________
Are the following factors in getting dental treatment done? Fear:
Time:
Money:
Yes
Yes
Yes
______________
No
No
No
How do you feel about the appearance of your face and smile?
__________________________________________________________________ ______________
Is there anything you don’t like about your teeth? Please circle all that apply:
crooked teeth
yellow/dark
teeth are different colors
crowding
spaces/gaps
missing teeth
tooth size
tooth shape
gummy smile
underbite
overbite
ugly old crowns
metal fillings
sensitivity
gum recession
other: _________________________________
____________________________________
Have you ever had orthodontic treatment? When?
______________________________________________ ___________________________________
Is any part of your mouth sensitive to temperature, pressure, eating or drinking? Where?
_____________________________________________ ____________________________________
Have you been told that you have gingivitis or periodontitis (gum disease)?
_______________________________________________ __________________________________
Have you lost any teeth? From what cause?
_______________________________________________________
Have the teeth been replaced?
_________________________________________________________
Do you wear denture or partial dentures? Are they comfortable?
_________________________
_______________________
________________________________________________________ _________________________
2
TMJ QUESTIONNAIRE
Do you ever have a burning or painful sensation in your mouth?
Yes
No
Do you notice a popping, clicking, or grinding noise when you open or close?
Yes
No
Do you ever awaken with an awareness of your teeth or jaws?
Yes
No
Are you aware of clenching during the daytime?
Yes
No
Have you ever been told you grind your teeth during sleep?
Yes
No
Do you have trouble opening your mouth widely?
Yes
No
Does your jaw lock open or closed?
Yes
No
Do you feel your bite is different, unstable or uncomfortable?
Yes
No
What professional advice or treatment have you had regarding your TMJ, headaches or pain
conditions/problems? ____________________________________
________
Do you have a grinding appliance/ “night guard”? Do you wear it? ________________ __________
SLEEP QUESTIONNAIRE
Please complete the following “Epworth Sleepiness Scale” by answering what chance you will doze off
in the following situations. Answer each with a 0, 1, 2, or 3.
0 = no chance of dozing, 1 = slight chance of dozing,
2 = moderate chance of dozing, 3 = high chance of dozing
Sitting and Reading
Watching TV
Sitting inactive in a public place (eg in a theatre or a meeting)
As a passenger in a car for an hour
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
____
___
_____
__
___
___
___
____
__
____
__
_____
__
_____
______
_
TOTAL
____
___
Do you become easily fatigued? At what time of day? __________________ ___________________
Do you snore, or have you been told that you do? __ _______________________________________
Do you have problems with insomnia? _____ ______________________________________________
Do you sleep well? How long? _______________________________________ _________________
Do you dream? How often? ____________________________ _______________________________
Do you have trouble falling asleep or staying asleep? ___________________ ____________________
Do you wake up with a headache?
Yes
No
Have you had chronic sleepiness, fatigue or weariness that you can’t explain?
Yes
No
Have you been more irritable or short tempered?
Yes
No
Have you felt that your memory and/or intellect is impaired?
Yes
No
Have you been told that you stop breathing while sleeping?
Yes
No
About how many times per night do you wake up?
Yes
No
Would you rate the quality of your sleep as (circle)
Good
Fair
Poor?
Do you have difficulty breathing through your nose?
Yes
No
Present body Weight: ____________lbs. Height ____________ ft. ____________ inches.
Have you ever had a sleep study?
Yes
No
Have you been diagnosed or treated for a sleep disorder?
Yes
No
Have any immediate family been diagnosed or treated for a sleep disorder?
Yes
No
What professional advice or treatment have you received about your snoring or sleep apnea?
If you sought treatment for a sleep disorder, did it help?
Yes
No
3
MEDICAL QUESTIONNAIRE
Do you have a current medical problem?
Yes
If Yes, please describe: _____________
No
___________________________________
Family Physician: ____________________________________ Phone Number: ___
Are you taking any medications, non-prescription drugs, or herbal supplements?
If Yes, please list them, including dosage and what they are prescribed for?
_______
Yes
No
____________________________
_______
_____________ _________________________
_____
________
___________________________
___________
________________________________
Do you have any allergies?
Yes
If Yes, to what? __________
No
___________________
Have you ever had bacterial endocarditis?
Do you have: congenital heart disease?
an artificial heart valve?
an artificial joint(s)?
a cardiac transplant?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Have you been recommended to take antibiotics before dental treatment?
Do you experience headaches or migraines? What time of day?
Do you experience neck pain or stiffness?
Do your ears feel stuffy, itchy or congested?
Do you experience pressure behind the eyes?
Do you experience dizziness?
Do you smoke or use tobacco products?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
If Yes, how often? ________________________
Did you smoke or use tobacco products in the past?
Do you want to quit?
Yes
Yes
No
No
If Yes, for how long? ______________________
When did you quit? ______
Do you currently see, or have you seen, a(n):
ENT (ears, nose and throat doctor):
Chiropractor:
Neurologist:
Present
Present
Present
Past
Past
Past
___________
Never
Never
Never
Have you ever had any of the following? Please circle those that apply:
Chest Pain/Angina
Diabetes
Liver Disease
Shortness of Breath
Arthritis
Hepatitis
High Blood Pressure
Asthma
Kidney Disease
Pacemaker
Bulimia
Lung Disease
Epilepsy/Seizures
Cancer Sores
Tuberculosis
Cancer
HIV/AIDS
Bleeding Disorder
Radiation
Stroke
Neurological Disorder
Chemotherapy
Cold Sores
Psychological Disorder
Latex Sensitivity
Anxiety
Depression
4
Do you have any disease, condition, or problem not listed?
_________
For WOMEN only:
Are you pregnant?
If Yes, what is your due date? ___________
Are you nursing?
Are you planning a pregnancy?
Are you taking birth control pills?
_______________________________
Yes
No
_________________________
Yes
Yes
Yes
No
No
No
5
DENTAL HYGIENE QUESTIONNAIRE
When was your last professional dental cleaning?
Has a previous dental hygienist or dentist expressed concern or diagnosed you with any of the
following gum health conditions? (please circle)
gingivitis
receding gums
gum (periodontal) disease
bone changes around your teeth
deep 'pockets'
bleeding gums
How often do you: floss? ____________________
brush? ________________
Do you use a Manual or Electric toothbrush? (circle one)
If electric, which one? ______ _______
Do you regularly use any of the products? (circle)
mouth wash
toothpicks
floss picks
threaders
tongue cleaner
other: ___
Do your gums bleed when you: (circle)
Eat
_____
floss handle
______________
Brush
Floss?
Are you concerned you may frequently have mouth odor?
Yes
No
Do your teeth ever feel loose, or have you noticed teeth shifting?
Yes
No
Are there teeth or areas of you mouth you find difficult to clean? ___________
_________________
Do you have a very sensitive gag reflex?
Yes
No, normal
There are certain health conditions that can increase a persons risk for oral diseases, or change the
approach or outcome treatment. Please circle any that may apply to you. Please excuse any
repetition from previous aspect of this medical questionnaire. If you are curious how any of these
conditions may affect your dental health, please ask!
Current Smoker
Previous Smoker
Diabetes
Elevated blood sugars
Pregnant
Osteoporosis
High Blood Pressure
Depression
Stress
Asthma
Obesity
Heart Disease
Stroke
Medication
What is your comfort level for dental hygiene treatment?
1-extremely anxious..... 10-love it! __
__
Do you have any good, or not-so-good, dental hygiene experiences you would like to share with us so
that we may better care for your individual needs?
_________________________________
__________________________
Is there anything we can do to make your cleaning more comfortable for you?
___________________
_____________
THANK YOU FOR TAKING THE TIME TO COMPLETE THESE QUESTIONNAIRES, IT IS APPRECIATED!!
EVOLUTION DENTAL
6