YOUR TRUSTED PETERBOROUGH DENTIST

Whether you’re seeking information prior to a visit to our office or need further resources following a procedure, Lakeridge Dentistry has you covered. Below, we have provided forms for you to check out when you’re seeking information.

You may download, print and fill out the required forms or simply fill in the eForms below.

New Patient Form
Dental History Form
Medical History Form

NEW PATIENT FORM

Whom may we thank for referring you?

Name:

I prefer to be called:

Gender

Male

Female

Birth date:

Age:

DL/ID

Home Address:

City:

Province:

Postal Code:

Home Phone:

Work:

ext.

Cell:

Email:

Check preferred contact:

Telephone Home

Telephone Work

Cell Phone

Employer:

Occupation:

Employer's Address:

City:

Province:

Postal Code:

Insurance Company Name:

Phone:

Group/Policy#:

Insured ’s Name:

Insured ’s Birthdate:

Relation:

ID/Certificate or Employee#

Insured ’s Employer:

Thank you! Your message has been successfully sent. We will contact you very soon!

DENTAL HISTORY

Name:

Referred by

How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

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 (other than cleaning):

I routinely see my dentist every:

3 months

4 months

6 months

12 months

Not routinely

What is your immediate concern?

PERSONAL HISTORY

Are you fearful of dental treatment?

Yes

If yes, how fearful on a scale of 1 (least) to 10 (most)?

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

BITE AND JAW JOINT

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

Yes

Do you have problems chewing gum?

Yes

Do you have problems chewing hard foods (bagels, protein bars, etc)?

Yes

Have your teeth become shorter, thinner, or worn in past 5 years?

Yes

Are your teeth crowding or developing spaces?

Yes

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 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 worn) a bite appliance?

Yes

TOOTH STRUCTURE

Have you had any cavities within the past 3 years?

Yes

Do you have difficulty swallowing any food due to lack of saliva?

Yes

Do you feel any holes on the biting surface of your teeth?

Yes

Are any teeth sensitive to hot, cold, biting, sweets?

Yes

Do you avoid brushing any part of your mouth due to sensitivities?

Yes

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

Yes

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

Yes

Does food get caught between any teeth?

Yes

GUM AND BONE

Do your gums bleed when brushing or flossing?

Yes

Have you been treated for gum disease?

Yes

Have you 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 in your family with a history of periodontal disease?

Yes

Have you experienced gum recession?

Yes

Have you ever had any teeth become loose without injury?

Yes

Do you have difficulty eating an apple?

Yes

Have you experienced a burning sensation in your mouth?

Yes

type your full name*

today's date**

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MEDICAL HISTORY

Name:

Nickname:

Age:

Name of Physician and their specialty:

Most recent physical exam:

Purpose:

What is your estimate of your general health?

Excellent

Good

Fair

Poor

DO YOU HAVE or HAVE YOU EVER HAD

Hospitalization for illness or injury

Yes

If yes, explain

Allergic reaction to:

Other allergies:

heart problems or cardiac stent within last 6 months

Yes

history of infective endocarditis

Yes

artificial heart valve, repaired heart defect (PFO)

Yes

pacemaker or implantable defribrillator

Yes

artificial prosthesis (heart valve or joints)

Yes

rheumatic or scarlet fever

Yes

high or low blood pressure

Yes

a stroke (taking blood thinners)

Yes

anemia or other blood disorder

Yes

prolonged bleeding due to a slight cut (INR>3.5)

Yes

emphysema, sarcoidosis

Yes

tuberculosis

Yes

asthma

Yes

breathing or sleep problems (i.e. snoring, sinus)

Yes

kidney disease

Yes

liver disease

Yes

jaundice

Yes

thyroid, parathyroid disease, or calcium deficiency

Yes

hormone deficiency

Yes

high cholesterol or taking statin drugs

Yes

diabetes

Yes

stomach or duodenal ulcer

Yes

digestive disorders (i.e. gastric reflux)

Yes

osteoporosis/osteopenia (i.e. taking bisphosphonates)

Yes

arthritis

Yes

glaucoma

Yes

contact lenses

Yes

head or neck injuries

Yes

epilepsy, convulsions (seizures)

Yes

neurologic problems (attention deficit disorder)

Yes

viral infections and cold sores

Yes

any lumps or swelling in the mouth

Yes

hives, skin rash, hay fever

Yes

venereal disease

Yes

hepatitus

Yes

if yes, type:

HIV/AIDS

Yes

tumor, abnormal growth

Yes

radiation therapy

Yes

chemotherapy

Yes

emotional problems

Yes

psychiatric treatment

Yes

antidepressant medication

Yes

alcohol/drug dependency

Yes

ARE YOU:

presently being treated for any other illness

Yes

aware of a change in your general health

Yes

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

Yes

taking dietary supplements

Yes

often exhausted or fatigued

Yes

subject to frequent headaches

Yes

a smoker or former smoker

Yes

considered a touchy person

Yes

often unhappy or depressed

Yes

taking birth control pills

Yes

label EN

Yes

prostate disorders

Yes

If yes to any of the above, explain

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

type your full name*

today's date*

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