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Home
About Us
Doctors
Services
Children’s Dentistry
Cosmetic Dentistry
Crown and Bridge
Emergency Care
Functional Orthodontics
Invisalign
Oral Hygiene
Periodontics
Prosthetics
Root Canals
TMJ Therapy
Wisdom Teeth
Online Forms
Dental History Form
Health History Form
CDCP
Contact Us
Blog
Name
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Office Information
Exploits Valley Dental Office
(709) 489-3660
4 Pinsent Drive
Grand Falls-Windsor, NF A2A 2R6
Patient Information
Patient Name
(Required)
First
Last
Home Phone
(Required)
Date
(Required)
MM slash DD slash YYYY
PID
Address 1
(Required)
Address 2
City and Province / State
(Required)
Postal / Zip Code
(Required)
Medical Alert
Condition
Premedication
Usual Dentist
Hygienist
Dental Concerns
Are you experiencing any dental problems?
(Required)
Yes
No
If yes, please describe your dental problem.
Date of your last dental visit
MM slash DD slash YYYY
Dental cleaning
MM slash DD slash YYYY
When were X-rays taken last?
MM slash DD slash YYYY
Regular Dental Care and Oral Symptoms
1. Have you been seeing a dentist regularly?
(Required)
Yes
No
2. Are there any growths or sore spots in your mouth?
(Required)
Yes
No
If yes, please describe the growths or sore spots.
3. Have you noticed any loose teeth, or have any of your teeth shifted?
(Required)
Yes
No
4. Does food get caught between your teeth?
(Required)
Yes
No
5. Are any of your teeth sensitive to heat, cold, sweets or pressure?
(Required)
Yes
No
6. Have you been advised to take antibiotics before a dental appointment?
(Required)
Yes
No
Oral Hygiene
7. Do you use dental floss, proxabrush, or stimudents?
(Required)
Yes
No
How often?
8. How often do you brush your teeth?
(Required)
Do you feel that you have bad breath?
(Required)
Yes
No
Previous Dental Treatments
9. Have you ever had one of the following?
Periodontal treatment? Treatment of the gums.
(Required)
Yes
No
Orthodontic treatment? To straighten or realign teeth.
(Required)
Yes
No
A bite plate or any other appliance?
(Required)
Yes
No
Your bite adjusted or teeth ground?
(Required)
Yes
No
Oral surgery? Surgery in or about the mouth / jaw joint, or implant surgery in one or both of your jaw joints?
(Required)
Yes
No
10. Jaw Problems. Do you have any of the following?
Popping / clicking in your jaw joints?
(Required)
Yes
No
Pain in your jaw joints, around your ear, or side of your face?
(Required)
Yes
No
Difficulty in opening or closing?
(Required)
Yes
No
Pain when teeth are clenched?
(Required)
Yes
No
Pain / difficulty in chewing?
(Required)
Yes
No
Oral Habits
11. Do you have any of the following habits?
Clenching or grinding your teeth while awake or asleep?
(Required)
Yes
No
Biting your cheeks or lips regularly?
(Required)
Yes
No
Breathing through your mouth while awake or asleep?
(Required)
Yes
No
Hold foreign objects with your teeth? Examples: pencils, nails, pipes, pins, fingernails.
(Required)
Yes
No
Dental Anxiety and Appearance
12. Do you have any emotional concerns about having dental treatment?
(Required)
Yes
No
If yes, please explain your concerns.
13. Are you happy with the appearance of your teeth?
(Required)
Yes
No
If no, what would you like to see changed?
Previous Dental Experiences and Concerns
14. Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or do you have any questions or concerns?
(Required)
Yes
No
Please describe the experience, complication, questions, or concerns.
Signature
Guardian/Patient Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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Appointment Request
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