Patient Registration Form

* indicates required

Periodontal disease may be caused by a combination of several factors and the following questions are designed to help us identify them. The success of therapy is dependent upon this. Therefore, although some of the following questions may seem unrelated to your periodontal condition, they are all associated with proper management of your oral health.

All information provided is kept strictly confidential.

Emergency name & contact phone number?

Who is your family physician?

Date of last physical exam?

Are you taking blood thinners?YesNo

Are you taking or have you taken any drugs within the past year?....(example: aspirin, tranquilisers, steroids, etc.)*YesNoIf so, please list names and dosages of medications

Have you had heart surgery or joint replacement?YesNoIf Yes, when?

Do you have or have you ever had any of the following conditions:AsthmaHepatitis (liver disease)Rheumatic FeverTumor or GrowthThyroid/Parathyroid DisorderHeart MurmurKidney ProblemsHeat Problems - AnginaSinusitisArthritis or RheumatismHeart AttackRadiation or ChemotherapyUlcersHigh Blood PressureLupusTuberculosisTendency to FaintEmphysemaStrokeEpilepsyCancerHerpesScarlet FeverDiabetesGlaucomaAnaemiaAbnormal Blood CountJaundiceH.I.V.

For each of the questions below, check the box if your answer is YES.Has your general health changed in the past year?Have you ever had any serious illness or major operations?Have you had abnormal bleeding associated with previous tooth extraction, surgery, or trauma?Do you have any allergies? (food, dust, drugs, fur, latex, etc.)?

Are you allergic or have you had an adverse reaction to any of the following? (Check all that apply)Dental anaesthetics (novocaine, etc.)AspirinPenicillin or other antibioticsCodeineBarbituates (sleeping pills)Other drugsIf yes to other drugs, please list.

Do you smoke or have you ever smoked or used other tobacco products or recreational drugs?YesNoIf yes, what and how long?Date quit:

What is your reason for coming to this office?

Have you, in the past, ever had periodontal (gum) treatments?YesNoIf yes, list previous perio treatments?If so, by whom?

When did you last have your teeth cleaned?

For each of the questions below, check the box if your answer is YES.Have you had any swollen, bleeding or receeding gums?Have you noticed bad mouth odors or tastes?Have you noticed any loose teeth?Would you be willing to spend several minutes per day cleaning your teeth?Are you satisfied with the appearance of your teeth?Have you ever had orthodontic treatment (braces)?Do you breathe primarily through your mouth?Do you have a dry mouth?

How often do you brush your teeth?Once per dayTwice per dayThree or more times per day

What type of brush do you use?HardMediumSoftExtra Soft

Are you pregnant?YesNoDon't KnowIf yes, when is your expected due date?

Have you reached menopause?YesNo

NOTE: certain medications (e.g. antibiotics) may inhibit the effectiveness of oral contraceptives.

*Please ensure consent acceptance is checked. Form will not submit otherwise.
I hereby give consent to have a periodontal (dental) examination and or relief of pain treatment. This treatment may include use of various medications such as: local anaesthetics (freezing), antibiotics, analgesics (pain killers) and others as required.