New patient questionnaire Personal informationTitle*Mr.Ms.Mrs.First name*Last name*Email Gender*FemaleMaleBirthdate* Date Format: MM slash DD slash YYYY Address*City*Province*Postal code*Preferred phone number*Alternate phone numberSpouse's nameDentistPhysicianHow were you referred to us?*Dental insuranceDo you have dental insurance?*YesNoPrimary insurance companyPrimary policy holder nameIf you are not the primary policy holder, please provide their date of birth Date Format: MM slash DD slash YYYY Primary group or policy numberPrimary employee, ID, or certificate numberDo you have a secondary dental insurance policy?YesNoSecondary insurance companySecondary policy holder nameIf you are not the secondary policy holder, please provide their date of birth Date Format: MM slash DD slash YYYY Secondary group or policy numberSecondary employee, ID, or certificate numberDenture historyDo you currently have a denture(s)?*YesNoWhat type of upper denture do you have?NonePartial upper dentureComplete upper dentureImplant-supported upper dentureWhen was your most recent upper denture made?How many upper dentures have you had?What type of lower denture do you have?NonePartial lower dentureComplete lower dentureImplant-supported lower dentureWhen was your most recent lower denture made?How many lower dentures have you had?Who made your denture(s)?DentistDenturistDo your gums get sore under your denture(s)?YesNoDo you brush your gums under your denture(s)?YesNoDo you wear your denture(s) to bed at night?YesNoDoes your denture(s) fit well?YesNoAre you happy with the appearance of your denture(s)?YesNoWhat don't you like about the appearance of your denture(s)?Are there any foods you have trouble eating?YesNoWhat foods do you have trouble eating?Do you use denture adhesive?YesNoWhat 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 historyWhen 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?*YesNoHave you had dental x-rays in the past 2 years?*YesNoDo you have any dental work in progress at this time?*YesNoIf yes, please describe.Do you have sensitive teeth?*YesNoI have no remaining teethIf yes, please describe.Do your gums bleed?*YesNoDo you often have a bad, unpleasant, or strange taste in your mouth?*YesNoIf yes, please describe.Do you experience pain, clicking, or popping in your jaw joint?*YesNoDo you experience facial, neck, or head pain?*YesNoDo you grind or clench your teeth?*YesNoDo you have dental implants?*YesNoHave you ever had an accident or trauma to your neck or jaw?*YesNoIf yes, please describe.Do you currently have any sore spots in your mouth?*YesNoDo you have any habits that affect your mouth?*YesNoIf yes, please describe.Medical historyDo you have a family physician that you see regularly?*YesNoAre you under the care of a physician for a specific health concern?*YesNoIf yes, please describe.Have you recently lost or gained a significant amount of weight?*YesNoDo you smoke or use chewing tobacco?*YesNoDo you have frequent indigestion?*YesNoAre you pregnant?*YesNoDo you have any of the following health issues? Please select all that apply.* Alcohol or drug dependency Angina pectoris Anorexia Arthritis Asthma Bleeding disorder Bulimia Cancer Chemotherapy or radiation Cholesterol problems Cold sores COPD Depression Diabetes Type 1 Diabetes Type 2 Difficulty breathing Dizziness or fainting Emphysema Epilepsy or seizures Fibromyalgia Heart attack Heart disease Heart murmur Hepatitis A Hepatitis B Hepatitis C Herpes virus High blood pressure HIV or AIDS HPV Immune deficiency Kidney disease Kidney stones Liver disease Low blood pressure Nervousness Psychological disorder Rheumatic fever Sexually transmitted disease Stroke Tuberculosis No health issues 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?*YesNoDo 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 hereYes, I consentCAPTCHA