Patient's form | Hummingbird Dental | Voted Top Choice Richmond Hill Dentist

Do you have or have you ever had any of the following?

Chest Pain/Angina
Heart Attack
High Blood Pressure
Emphysema
Asthma
Epilepsy/Seizures
Thyroid Disease
Kidney Disease
Cancer
Chemotherapy/Radiation
Psychiatric Disorder
Tuberculosis
Arthritis
Strock
Osteoporosis/Osteopenia
Stomach Ulcers
Diabetes
Drug/Alcohol Dependency
Pacemaker
Sinusitis

Are there any conditions or diseases not listed above that you have or have had?

YES
NO

If yes, please list:

Detail

For women only: Are you pregnant, breastfeeding, or taking birth control pills?

YES
NO

DENTAL HISTORY

What are the main reasons for your visit?

When was your last dental visit?

When did you last have dental x-rays?

How often do you: Brush your teeth?

Floss your teeth?

Are any of your teeth sensitive to cold, heat or chewing?

YES
NO

Do you get food jammed in between your teeth?

YES
NO

Have you ever had professional treatment for your gums?

YES
NO

Are you aware of clenching/grinding your teeth during the day or night?

YES
NO

Do your jaw joints click, pop, or make grating noises?

YES
NO

Have you ever been in a vehicle accident or experienced any blows to your jaw?

YES
NO

Have you ever had any implant surgery in one or both of your jaws or jaw joints?

YES
NO

If “yes”, who performed the surgery and when was it done?

Detail

Are you being followed up by a dental specialist?

YES
NO

Do you suffer from headaches? If “yes”, approximately how many per month?

YES
NO

Have you ever had your wisdom teeth removed?

YES
NO

Have you had orthodontic treatment (braces)?

YES
NO

If you play sports, do you wear a mouthguard?

YES
NO

SMILE ANALYSIS

Are you pleased with the appearance of your teeth?

YES
NO

If not, what would you like to improve?

Detail

Do you have gaps between your teeth that you would like closed?

YES
NO

Would you like to have your teeth whiter?

YES
NO

Do you have chipped or broken teeth which you would like to fix?

YES
NO

Do you have any crooked or misaligned teeth that bother you?

YES
NO

To the best of my knowledge, the above information is correct.

Please type "I confirm"

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Hummingbird Dental Clinic in Richmond Hill

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SMILE ANALYSIS

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