Nechako Ridge Denturist Corp
Step
1
of
4
- Patient Information
25%
NEW PATIENT INTAKE FORM
Personal Information
Patient Name
*
First
Last
Date of Birth
*
YYYY slash MM slash DD
Gender
*
Male
Female
Other
Address
*
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Phone Number
*
Alternative Phone Number
Email
*
Personal Health Number
How did you hear about us?
Extended Benefits
Do you have extended benefits?
*
Yes
No
Primary Carrier
Carrier Name
Group or Policy Number
Certificate or ID Number
Employer
Phone
Spouse's Name
Spouse's DOB
YYYY slash MM slash DD
Secondary Carrier
Carrier Name
Group or Policy Number
Certificate or ID Number
Employer
Phone
Spouse's Name
Spouse's DOB
YYYY slash MM slash DD
Emergency Contact Details
Name
*
First
Last
Relationship
*
Phone
*
NEW PATIENT INTAKE FORM
Health history
Do you smoke?
*
Yes
No
Do you have allergies that you are aware of?
*
Yes
No
Are you allergic to any of the following?
Latex
Metals
Plastics
Has your weight, appetite, or energy level changed dramatically, recently?
*
Yes
No
Have you tested HIV positive?
*
Yes
No
Have you tested positive for hepatitis A B C?
*
Yes
No
Do you have any of the following?
ALCOHOL OR DRUG DEPENDENCY
ALZHEIMER'S
ANOREXIA
ARTHRITIS
ASTHMA
BLEEDING DISORDER
BULIMIA
CANCER
COLD SORES
COPD
DEPRESSION
DIABETES
DIFFICULTY BREATHING
DIZZINESS OR FAINTING
EMPHYSEMA
EPILEPSY OR SEIZURES
FIBROMYALGIA
HEART ATTACK
HEART DISEASE
HIGH BLOOD PRESSURE
IMMUNE DEFICIENCY
KIDNEY DISEASE
LIVER DISEASE
LOW BLOOD PRESSURE
MIGRAINES
NERVOUSNESS
PARKINSON'S DISEASE
PSYCHOLOGICAL DISORDER
RADIATION OR CHEMOTHERAPY
SEXUALLY TRANSMITTED INFECTIONS (STI)
STROKE
TMJ ISSUES
TUBERCULOSIS
Other
Do you wish to speak privately to the Denturist about any medical condition(s)?
*
Yes
No
Current Medications
NEW PATIENT INTAKE FORM
Denture & Dental History
Who is your dentist?
Have you ever had dentures?
*
Yes
No
Current Appliance
*
Complete Upper Denture
Complete Lower Denture
Partial Upper Denture
Partial Lower Denture
Implant Overdenture
None
Appliance Age
Under 1 year
1 to 5 years
5 to 10 years
10 or more years
NA
When was the last time you have seen a dentist?
Under 6 months
6 months to 1 year
1 to 2 years
2 to 5 years
5 or more years
Do you have teeth to be extracted?
*
Yes
No
Who is extracting the teeth?
Extraction Date
YYYY slash MM slash DD
Do you have dental work to be completed?
*
Yes
No
Do you have dental implants?
*
Yes
No
When were they checked last?
YYYY slash MM slash DD
Oral cancer screening has been done in the last year?
*
Yes
No
Are you happy with your appliance(s)?
*
Yes
No
Do you chew well with your dentures?
*
Yes
No
Do you wear your dentures at night?
*
Yes
No
Are your dentures loose?
*
Yes
No
Do you regularly wear denture glue/adhesive?
*
Yes
No
Do you grind or clench your teeth?
*
Yes
No
Are your dentures comfortable?
*
Yes
No
Do you gag easily?
*
Yes
No
Do you chew gum/mints?
*
Yes
No
Do you clean your dentures 2x a day?
*
Yes
No
How long have you been wearing dentures?
How many dentures have you had?
Please indicate what types of changes you would like to see in your new denture(s)
*
Tooth Size
Tooth Length
Tooth Shape
Tooth Colour
Lip Support
No Changes
NEW PATIENT INTAKE FORM
Consent
Consent
*
I, the undersigned, certify the given information is accurate, true and to the best of my knowledge.
*
Patient signature
*
Decision Maker
Consent
I, the undersigned, certify that I am the substitute decision maker, and the given information is accurate, true and to the best of my knowledge for the listed patient.
Name
First
Last
Decision maker signature
Comments
This field is for validation purposes and should be left unchanged.
Nechako Ridge Denturist Corp
[email protected]