Patient Form - Family & Emergency Dental Clinic in Nepean

Date of last dental exam

Cleaning

Xrays

PLEASE CHECK YES OR NO

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Is there a problem you would like treated immediately?*

Yes
No

Have you been seeing a dentist regularly?*

Yes
No

Have you ever had periodontal treatment (treatment of the gums)?*

Yes
No

Have you ever had orthodontics (straighten your teeth)?*

Yes
No

Have you ever had a bite plate or nightguard?*

Yes
No

Have you ever had your bite adjusted or teeth ground?*

Yes
No

Have you ever had oral surgery to your mouth or jaw?*

Yes
No

Are you currently seeing a dental specialist?*

Yes
No

Are there any growths or sores in your mouth?*

Yes
No

Do your gums bleed when brushing or do you suffer pain and swelling?*

Yes
No

Have you noticed any loose teeth, or have any of your teeth shifted?*

Yes
No

Does food catch between your teeth?*

Yes
No

Are any of your teeth sensitive to hot, cold or sweets?*

Yes
No

Have you been advised to take antibiotics before a dental appointment?*

Yes
No

Do you use dental floss, proxabrush or stimudents?*

Yes
No

How often?

Do you feel you have bad breath?*

Yes
No

How often do you brush your teeth?

Have you ever experienced any popping/clicking/pain in your jaw around your ear?*

Yes
No

Any difficulty opening or closing/pain when teeth are clenched?*

Yes
No

Do you clench or grind your teeth?*

Yes
No

Do you bite your cheeks or lips?*

Yes
No

Do you have any emotional concerns about having dental treatment?*

Yes
No

Are you happy with the appearance of your teeth?*

Yes
No

Step 1 of 4

PLEASE CHECK YES OR NO

YN

Contact Us

Our Practice

Clinic Hours

Tel: 613-227-6453