New Patients Info

At Appleway Dental Clinics, we are always excited to meet new patients from Red Deer and surrounding areas. Our team will work with you to develop a comprehensive treatment plan to help you achieve the healthy, beautiful smile you have always wanted. If you’re planning to visit us for any dental treatment, schedule an appointment today.

Want to help lower your wait time? Please fill out our New Patient form below.

Patient Information Dental History Medical History

Medical and Dental History

PERSONAL INFORMATION

First Name*

Middle Name*

Last Name*

Date of Birth

Gender

Martial Status

How did you hear about our office?

Address

Street

City

Province

Postal Code

Contact Information

Cell Phone

Home Phone

Emergency Contact Person

Emergency Contact Phone

Insurance Information (Primary & Secondary)

Name of Insured

Is insured a patient?

Insurance Plan Name

Insured's Birth Date

Insurance Plan Name and Address

ID #

Group #

DENTAL HISTORY

Referred by

How would you rate the condition of your mouth?

Previous Dentist

How long have you been a patient?

Date of most recent dental exam

Date of most recent x-rays?

Date of most recent treatment

I routinely see my dentist every

What is your immediate concern?

PERSONAL HISTORY

Have you had an unfavorable dental experience?

Yes

Have you ever had complications from past dental treatment?

Yes

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes

Have you had any teeth removed?

Yes

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change?

Yes

Have you ever whitened (bleached) your teeth?

Yes

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes

Have you been disappointed with the appearance of previous dental work?

Yes

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes

Do you/would you have any problems chewing gum?

Yes

Do you/would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?

Yes

Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Yes

Are your teeth crowding or developing spaces?

Yes

Bite and Jaw Joint

Do you have more than one bite and squeeze to make your teeth fit together?

Yes

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Yes

Do you clench your teeth in the daytime or make them sore?

Yes

Do you have any problems with sleep or wake up with an awareness of your teeth?

Yes

Do you wear or have you ever worn a bite appliance?

Yes

Tooth Structure

Have you had any cavities within the past 3 years?

Yes

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Yes

Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

Yes

Do you have grooves or notches on your teeth near the gum line?

Yes

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

Yes

Do you get food caught between any teeth?

Yes

Gum and Bone

Do your gums bleed when brushing or flossing?

Yes

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes

Have you ever noticed an unpleasant taste or odor in your mouth?

Yes

Is there anyone with a history of periodontal disease in your family?

Yes

Have your ever experienced gum recession?

Yes

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes

Have you experienced a burning sensation in your mouth?

Yes

MEDICAL HISTORY

Name of Physician / and their specialty

Most recent physical examination

What is your estimate of your general health?

Do you have OR have you ever had:

1. Hospitalization for illness or injury

Yes

Other metals

Other allergic reactions

3. Heart problems, or cardiac stent

Yes

4. History of infective endocarditis

Yes

5. Artificial heart valve, repaired heart defect (PFO)

Yes

6. Pacemaker or implantable defibrillator

Yes

7. Artificial prosthesis (heart valve or joints)

Yes

8. Rheumatic or scarlet fever

Yes

9. High or low blood pressure

Yes

10. A stroke (taking blood thinners)

Yes

11. Anemia or other blood disorder

Yes

12. Prolonged bleeding due to a slight cut (INR>3.5)

Yes

13. Emphysema, sarcoidosis

Yes

14. Tuberculosis

Yes

15. Have you had recent exposure to communicable infectious diseases (measles, chicken pox, TB, Prion disease, or travel to endemic area)

Yes

16. In the last 24 hours have you had new cough, shortness of breath, fever, chills, diarrhea or other flu like symptoms

Yes

17. Asthma

Yes

18. Breathing or sleep problems (i.e. snoring, sinus)

Yes

19. Kidney disease

Yes

20. Liver disease

Yes

21. Jaundice

Yes

22. Thyroid, parathyroid disease, or calcium deficiency

Yes

23. Hormone deficiency

Yes

24. High cholesterol or taking statin drugs

Yes

25. Diabetes (HbA1c=_________)

Yes

26. Stomach or duodenal ulcer

Yes

27. Digestive disorders (i.e. gastric reflux)

Yes

28. Osteoporosis/osteopenia (i.e. taking bisphosphonates)

Yes

29. Arthritis

Yes

30. Glaucoma

Yes

31. Contact lenses

Yes

32. Head or neck injuries

Yes

33. Epilepsy, convulsions (seizures)

Yes

34. Neurologic problems (attention deficit disorder)

Yes

35. Viral infections and cold sores

Yes

36. Any lumps or swelling in the mouth

Yes

37. Hives, skin rash, hay fever

Yes

38. Venereal disease

Yes

40. HIV / AIDS

Yes

41. Tumor, abnormal growth

Yes

42. Radiation therapy

Yes

43. Chemotherapy

Yes

44. Emotional problems

Yes

45. Psychiatric treatment

Yes

46. Antidepressant medication

Yes

47. Alcohol / drug dependency

Yes

Are you:

48. Presently being treated for any other illness

Yes

49. Aware of a change in your general health

Yes

50. Taking medication for weight management (i.e. fen-phen)

Yes

51. Taking dietary supplements

Yes

52. Often exhausted or fatigued

Yes

53. Subject to frequent headaches

Yes

54. A smoker or smoked previously

Yes

55. Considered a touchy (sensitive) person

Yes

56. Often unhappy or depressed

Option 1

57. FEMALE – taking birth control pills

Yes

58. FEMALE – pregnant

Yes

59. MALE – prostate disorders

Yes

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

List all medications, supplements, and or vitamins taken within the last two years. Ask for an additional sheet if you are taking more than 6 medications. (Drug Purpose)

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

PATIENT CONSENT *

I consent

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