New Patient Form

Welcome to Anokhi Dental

So that we may provide you with the best possible care, please take the time to complete this form.

All information provided is completely confidential.

Title*
Prefix
Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Would you like to receive our e-news?*
- Yes
- No
Occupation
How did you hear about Anokhi Dental?*
Next of Kin*
In case of emergency
Contact Phone*
In case of emergency
MEDICAL HISTORY
Have you been under the care of a medical doctor or practitioner during the past two years?*
- Yes
- No
If yes, for what?
Doctor/Practitioner Name*
Contact Number*
Have you been a patient in hospital in the past five years?*
- Yes
- No
Are you taking any medications or drugs now?*
- Yes
- No
Have you ever taken any bisphosphonate medications?*
- Yes
- No
Are you taking vitamins or supplements now?*
- Yes
- No
Are you allergic to any medications, including penicillin?*
- Yes
- No
Please provide names and dosages if you have answered yes to any of the above
Please indicate which of the following you have (or have had) and provide details:
Heart Disease (angina, attack, dysrhythmia)*
- Yes
- No
Congenital heart disease (heart murmur, Prolapsed mitral valve)*
- Yes
- No
Rheumatic Fever/Endocarditis*
- Yes
- No
Heart Surgery*
- Yes
- No
Artificial heart valve or pacemaker*
- Yes
- No
Stroke*
- Yes
- No
High/Low Blood Pressure*
- Yes
- No
Bleeding abnormalities (warfarin therapy, Haemophilia)*
- Yes
- No
Respiratory Disease (asthma, bronchitis, Emphysema)*
- Yes
- No
Diabetes*
- Yes
- No
Thyroid Disease*
- Yes
- No
Kidney/Urogenital Disease*
- Yes
- No
Liver Disease (jaundice, cirrhosis)*
- Yes
- No
Digestive Disorders (reflux, leaky gut, Candida)*
- Yes
- No
Multiple Sclerosis*
- Yes
- No
Osteoporosis*
- Yes
- No
Arthritis/Artificial Joints (hip, knee etc)*
- Yes
- No
Malignancy*
- Yes
- No
Chemotherapy*
- Yes
- No
Radiotherapy*
- Yes
- No
Surgery*
- Yes
- No
Allergies (hay fever, latex)*
- Yes
- No
Neurological Disorders (anxiety, depression, Epilepsy, dementia)*
- Yes
- No
Chronic Fatigue Syndrome*
- Yes
- No
HIV/AIDS*
- Yes
- No
Hepatitis*
- Yes
- No
Tuberculosis*
- Yes
- No
Do you smoke or consume alcohol?*
- Yes
- No
General Fatigue*
- Yes
- No
Daytime Sleepiness*
- Yes
- No
Insomnia*
- Yes
- No
Irritability*
- Yes
- No
Unexpected Weight Gain*
- Yes
- No
Have you ever had a sleep study?*
- Yes
- No
Have you ever seen an Ear Nose Throat Specialist (ENT)?*
- Yes
- No
Please provide information if you have ticked "Yes" to any of the above or if you have any disease or condition not listed:*
Ladies are you:
Taking Birth Control*
- Yes
- No
Planning pregnancy*
- Yes
- No
Breastfeeding*
- Yes
- No
Undergoing IVF*
- Yes
- No
Please provide more information if you have ticked "Yes" to any of the above or if you have any disease or condition not listed:*
DENTAL HISTORY
What is the reason for your visit?*
When did you last visit a dentist?*
How often do you have dental examinations?*
Last dental cleaning?*
Last full mouth x-rays?*
How often do you brush your teeth?*
How often do you floss?*
What oral care products (toothpaste, mouthwash, etc) do you use?*
Do you have any dental problems now?*
- Yes
- No
If yes, please describe:*
Do your gums bleed or hurt?*
- Yes
- No
Do you experience bad breath or a bad taste in your mouth?*
- Yes
- No
Have you noticed any loose teeth or change in your bite?*
- Yes
- No
Does food get caught between your teeth?*
- Yes
- No
Do you experience mouth ulcers, cold sores or any other lesions?*
- Yes
- No
Have you every experienced dental infections?*
- Yes
- No
Have you had dental decay or fillings?*
- Yes
- No
Have you had any crowns or bridges placed in your mouth?*
- Yes
- No
Have you ever had root cancal treatment?*
- Yes
- No
Do you have dental implants?*
- Yes
- No
Are any of your teeth sensitive to:
Hot or Cold*
- Yes
- No
Sweet*
- Yes
- No
Biting or Chewing*
- Yes
- No
Do you experience difficulty chewing?*
- Yes
- No
Are you missing teeth?*
- Yes
- No
Do you wear dentures?*
- Yes
- No
Do you ever clench or grind your teeth?*
- Yes
- No
Have you ever had:
Your teeth ground or bite adjusted?*
- Yes
- No
A bite plate or mouthguard?*
- Yes
- No
Do you experience:
Clicking or popping of the jaw?*
- Yes
- No
Headaches, neck or shoulder tension?*
- Yes
- No
Tired jaws, especially in the morning?*
- Yes
- No
Are you sensitive to anaesthetics and/or dental materials?*
- Yes
- No
- Third Choice
Are you dissatisfied with the appearance of your teeth?*
- Yes
- No
- Third Choice
Do you feel nervous about having dental treatment?*
- Yes
- No
Have you ever had an upsetting dental experience?*
- Yes
- No
If you have answered "Yes" to any of the above, please provide more information below:
*
I understand that I must provide 24 hours of notice for rescheduling or cancelling an appointment or I will be charged a $100 fee. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all of the questions to the best of my knowledge. I will notify the dentist of any change in my health or medication.
Date*
Date Format: DD slash MM slash YYYY

New Patient Form

Welcome to Anokhi Dental

So that we may provide you with the best possible care, please take the time to complete this form.

All information provided is completely confidential.

MEDICAL HISTORY

Please indicate which of the following you have (or have had) and provide details:

Ladies are you:

DENTAL HISTORY

Are any of your teeth sensitive to:

Have you ever had:

Do you experience: