New patient questionnaire

Personal information

Title*

Mr.
Ms.
Mrs.

First name*

Last name*

Email

Gender*

Female
Male

Birthdate*

Address*

City*

Province*

Postal code*

Preferred phone number*

Alternate phone number

Spouse's name

Dentist

Physician

How were you referred to us?*

Dental insurance

Do you have dental insurance?*

Yes
No

Primary insurance company

Primary policy holder name

If you are not the primary policy holder, please provide their date of birth

Primary group or policy number

Primary employee, ID, or certificate number

Do you have a secondary dental insurance policy?

Yes
No

Secondary insurance company

Secondary policy holder name

If you are not the secondary policy holder, please provide their date of birth

Secondary group or policy number

Secondary employee, ID, or certificate number

Denture history

Do you currently have a denture(s)?*

Yes
No

What type of upper denture do you have?

None
Partial upper denture
Complete upper denture
Implant-supported upper denture

When was your most recent upper denture made?

How many upper dentures have you had?

What type of lower denture do you have?

None
Partial lower denture
Complete lower denture
Implant-supported lower denture

When was your most recent lower denture made?

How many lower dentures have you had?

Who made your denture(s)?

Dentist
Denturist

Do your gums get sore under your denture(s)?

Yes
No

Do you brush your gums under your denture(s)?

Yes
No

Do you wear your denture(s) to bed at night?

Yes
No

Does your denture(s) fit well?

Yes
No

Are you happy with the appearance of your denture(s)?

Yes
No

What don't you like about the appearance of your denture(s)?

Are there any foods you have trouble eating?

Yes
No

What foods do you have trouble eating?

Do you use denture adhesive?

Yes
No

What changes would you like to see in your new denture(s)

If you have never worn dentures, what do you know about them so far?

Dental history

When was your last visit with a dentist?*

At that visit, what procedure(s) did you have done?

Have you ever had any complications following a dental procedure?*

Yes
No

Have you had dental x-rays in the past 2 years?*

Yes
No

Do you have any dental work in progress at this time?*

Yes
No

If yes, please describe.

Do you have sensitive teeth?*

Yes
No
I have no remaining teeth

If yes, please describe.

Do your gums bleed?*

Yes
No

Do you often have a bad, unpleasant, or strange taste in your mouth?*

Yes
No

If yes, please describe.

Do you experience pain, clicking, or popping in your jaw joint?*

Yes
No

Do you experience facial, neck, or head pain?*

Yes
No

Do you grind or clench your teeth?*

Yes
No

Do you have dental implants?*

Yes
No

Have you ever had an accident or trauma to your neck or jaw?*

Yes
No

If yes, please describe.

Do you currently have any sore spots in your mouth?*

Yes
No

Do you have any habits that affect your mouth?*

Yes
No

If yes, please describe.

Medical history

Do you have a family physician that you see regularly?*

Yes
No

Are you under the care of a physician for a specific health concern?*

Yes
No

If yes, please describe.

Have you recently lost or gained a significant amount of weight?*

Yes
No

Do you smoke or use chewing tobacco?*

Yes
No

Do you have frequent indigestion?*

Yes
No

Are you pregnant?*

Yes
No

Do you have any of the following health issues? Please select all that apply.*

Do you have any of the following allergies? Please select all that apply.

Drug allergies
Environmental allergies
Latex allergy
Other

Please list all current medications.*

Have you ever experienced a bad reaction to any of the following medications? Please select all that apply.

Anaesthethic
Barbiturates (sleeping pills)
Codeine
Cortisone
Penicillin
Sulphonamides (sulfa drugs)
Tranquilizers
Other

Have you had any of the following surgeries? Please select all that apply.

Artificial heart valve
Artificial joint replacement
Heart surgery
Organ transplant
Pacemaker
Other

Have you ever had a serious illness that required hospitalization?*

Yes
No

Do you have any other health issues which have not already been addressed in this questionnaire?*

Click here to indicate that you hereby certify the information you are submitting to be complete and accurate.*

Yes, my information is complete and accurate

I consent to the collection, use, and disclosure of my Personal Information as set out in the Terms of Patient Consent*

Full Terms can be reviewed here

Yes, I consent

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Personal information

Dental insurance

Denture history

Dental history

Medical history

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