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Aberdeen Dental Centre

Adult - New Patient Registration


  Last name

  Mid name

  First name
City
Prov.
 Postal
APT#
*Home phone #:
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Cell #:
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Work phone #:
()- - -
Emergency Contact Details -
Phone #:
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Cell #:
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Insurance Information

Insurance Primary-
Insurance Secondary-

Assignment and Release
* I, the undersigned certify that I (or my dependent) have insurance coverage and assign directly to Aberdeen Dental all insurance benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.
* Consent: I consent to the diagnostic procedures and treatment by the dentist/dental hygienist necessary for proper dental care.

Medical History

Excellent Good Fair Poor
Please answer Yes or No to the following questions.
Do you have or Have you ever had:
1. Hospitalization for illness or injury Yes No
2. An allergic or bad reaction to any of the following:
3. Heart problems, or cardiac stent within the last six months Yes No
4. History of infective endocarditis Yes No
5. Artificial heart valve,repaired heart defect (PFO) Yes No
6. Pacemaker or implantable defibrillator Yes No
7. Orthopedic implant (joint replacement) Yes No
8. Rheumatic od scarlet fever Yes No
9. High or low blood pressure Yes No
10. A stroke (taking blood thinners) Yes No
11. Anemia or other blood disorder Yes No
12. Prolonged bleeding due to a slight cut (INR>3.5) Yes No
13. Pneumonia, Emphysema, Shortness of breath, Sarcoidosis Yes No
14. Tuberculosis, Measles, Chicken pox Yes No
15. Asthma Yes No
16. Breathing or sleep problems (i.e. Sleep apnea, Snoring, Sinus) Yes No
17. Kidney disease Yes No
18. Liver disease Yes No
19. Jaundice Yes No
20. Thyroid, Parathyroid disease, or Calcium deficiency Yes No
21. Hormone deficiency Yes No
22. High cholesterol or taking statin drugs Yes No
23. Diabetes(HbA1c=) Yes No
24. Stomach or duodenal ulcer Yes No
25. Digestive or eating disorders (e.g.Celiac disease, Gastric reflux, Bulimia, Anorexia) Yes No
26. Osteoporosis/Osteopenia (i.e.Taking bisphosphonates) Yes No
27. Arthritis Yes No
28. Autoimmune disease(i.e. Rheumatoid arthritis, Lupus, Scleroderma) Yes No
29. Glaucoma Yes No
30. Contact lenses Yes No
31. Head or neck injuries Yes No
32. Epilepsy, Convulsions (seizures) Yes No
33. Neurologic disorders (ADD/ADHD, prion disease) Yes No
34. Viral infections and cold sores Yes No
35. Any lumps or swelling in the mouth Yes No
36. Hives, Skin rash, Hay fever Yes No
37. STI/STD/HPV Yes No
38. Hepatitis Type) Yes No
39. HIV/AIDS Yes No
40. Tumor, Abnormal growth Yes No
41. Radiation therapy Yes No
42. Chemotherapy,immunosuppressive medication Yes No
43. Emotional difficulties Yes No
44. Psychiatric treatment Yes No
45. Antidepressant medication Yes No
46. Alcohol/ Recreational drug use Yes No
Are you:
47. Presently being treated for any other illness Yes No
48. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough,or diarrhea) Yes No
49. Taking medication for weight management Yes No
50. Taking dietary supplements Yes No
51. Often exhausted or fatigued Yes No
52. Experiencing frequent headaches Yes No
53. A smoker, smoked previously or use smokeless tobacco Yes No
54. Considered a touchy/ sensitive person Yes No
55. Often unhappy or depressed Yes No
56. Taking birth control pills Yes No
57. Currently pregnant Yes No
58. Diagnosed with a prostate disorder Yes No



List all medications, supplements, and or vitamins taken within the last two years.
Drug Purpose Drug Purpose
Please advise us in the future of any change in your medical history or any medications you may be taking.

Dental History

Excellent Good Fair Poor
Months/Years
3 Months 4 Months 6 Months 12 Months Not routinely
Personal History
1. Are you fearful of dental treatment? Yes No
How fearful,on a scale 1(least) to 10(most) 1 2 3 4 5 6 7 8 9 10
2. Have you had an unfavorable dental experience? Yes No
3. Have you ever had complications from past dental treatment? Yes No
4. Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes No
5. Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No
6. Have you had any teeth removed, missing teeth that never developed/ lost teeth due to injury/ facial trauma? Yes No
Gum and Bone
7. Do you have gums bleed or are they painful when brushing or flossing? Yes No
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No
9. Have you ever noticed an unpleasant taste or odor in your mouth? Yes No
10. Is there anyone with a history of periodontal disease in your family? Yes No
11. Have you ever experienced gum recession? Yes No
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes No
Tooth Structure
14. Have you had any cavities within the past 3 years? Yes No
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No
16. Do you feel or notice any holes(i.e.pitting,craters)on the biting surface of your teeth? Yes No
17. Are any teeth sensitive to hot, cold, biting sweets, or do you avoid brushing any part of your mouth? Yes No
18. Do you have grooves or notches on your teeth near the gum line? Yes No
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No
20. Do you frequently get food caught between any teeth? Yes No
Bite and Jaw Joint
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No
22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? Yes No
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No
24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes No
25. Are your teeth becoming more crooked, crowded, or overlapped? Yes No
26. Are your teeth developing spaces or becoming more loose? Yes No
27. Do you have trouble finding your bite/ need to squeeze/ tap your teeth together/ shift your jaw to make your teeth fit together? Yes No
28. Do you place your tongue between your teeth or close your teeth against your tongue? Yes No
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No
30. Do you clench or grind your teeth together in the daytime or make them sore? Yes No
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? Yes No
32. Do you wear or have you ever worn a bite appliance? Yes No
Smile Characteristics
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? Yes No
34. Have you ever whitened (bleached) your teeth? Yes No
35. Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes No
36. Have you been disappointed with the appearance of previous dental work? Yes No

Sleep Screening Questionnaire

Height: Weight:

Please answer the questions below to help us assess the possibility of a sleep disorder which may be related to your dental and overall health. There is often a correlation between grinding of the teeth. TMJ, disorders, breakdown of the teeth and sleep disorders. Sleep apnea may also increase your risk for many different health conditions including heart attack and stroke. If you are here with your child (under 16), please fill out the lower portion marked “For children only” for your child.

The Epworth Sleepiness Scale
Use the following scale to choose the most appropriate number for each situation:
0 = Would Never Doze 1 = Slight Chance Of Dozing
2 = Moderate Chance Of Dozing 3 = High Chance Of Dozing
Situation
Siting and reading
Watching television
Sitting inactive in a public place (e.g. theatre, meeting)
As a car passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic

TOTAL SCORE:

Have you ever been diagnosed with
Impaired Cognition (i.e. difficulty concentrating or thinking) Yes No
Mood Disorders/Depression Yes No
Insomnia Yes No
Hypertension (high blood pressure) Yes No
Ischemic Heart Disease (Coronary Artery Disease/Atherosclerosis) Yes No
History of Stroke Yes No
Sleep Apnea Yes No
If yes: Did you try to use CPAP Yes No
TMJ Problems significant enough to require treatment Yes No
Gastric Reflux (GERD)or Heartburn Yes No
Are you aware of (or have you been told)
Snoring on a regular basis Yes No
Feeling tired or fatigued on a regular basis Yes No
Clenching or Grinding your teeth (bruxism) Yes No
Having frequent headaches Yes No
Your neck size being > 17 inches (male)or > 16 inches (female) Yes No
Anyone in your family having sleep apnea Yes No
Stopping breathing when sleeping/awakening with a gasp Yes No
For children only (filled out by parent or guardian)
Are you aware of your child
Snoring/noisy breathing while sleeping Yes No
Grinding his or her teeth Yes No
Wetting the bed Yes No
Having difficulty in school/learning Yes No
Being treated for ADD or ADHD Yes No
Breathing primarily through their mouth Yes No
Having frequent nightmares/night terrors Yes No
Having frequent ear aches Yes No
Dental Exam Findings
Evidence of Bruxism
Scalloping of the tongue
Crowded airway
Tori or Bone Loss
Anterior wear
Retrognathia/Class II


STOP-BANG Sleep Apnea Questionnaire
Chung F et al Anesthesiology 2008 and BJA 2012
STOP
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? Yes No
Do you often feel TIRED, fatigued, or sleepy during daytime? Yes No
Has anyone OBSERVED you stop breathing during your sleep? Yes No
Do you have or are you being treated for high blood PRESSURE? Yes No

*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)