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180 9 St NE #100, Calgary, AB T2E 0P4, Canada
(403) 294 1077
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We Accept The Canadian Dental Care Plan (CDCP). Schedule Your Appointment Today!

180 9 St NE #100, Calgary, AB T2E 0P4, Canada
info@alpinedentalcare.ca

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About
New Patients
- New Patient Forms
Patient Resources
- Videos
Services
Referral
Contact

About
New Patients
- New Patient Forms
Patient Resources
- Videos
Services
Referral
Contact

Dental History

Patient's Legal Name:(Required)

First Last

Date of Birth(Required)

Month

Day

Year

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:

Month

Day

Year

Date of most recent treatment (other than a cleaning):

Month

Day

Year

Date of most recent x-rays:

Month

Day

Year

I routinely see my dentist every:

3 mo.

4 mo.

6 mo.

12 mo.

Not routinely

What is your immediate concern?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY

1. Are you fearful of dental treatment?

No

Yes

How fearful on a scale of 1 (least) to 10 (most)

1

2

3

4

5

6

7

8

9

10

2. Have you had an unfavorable dental experience?

No

Yes

3. Have you ever had complications from past dental treatment?

No

Yes

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

No

Yes

5. Have you had any teeth removed or missing teeth that never developed?

No

Yes

GUM AND BONE

6. Do your gums bleed or are they painful when brushing or flossing?

No

Yes

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

No

Yes

8. Have you ever noticed an unpleasant taste or odour in your mouth?

No

Yes

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

No

Yes

10. Have you ever experienced gum recession?

No

Yes

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

No

Yes

12. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

No

Yes

TOOTH STRUCTURE

13. Have you ever had any cavities within the last 3 years?

No

Yes

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

No

Yes

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

No

Yes

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

No

Yes

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

No

Yes

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

No

Yes

19. Do you frequently get food caught between any teeth?

No

Yes

BITE AND JAW JOINT

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

No

Yes

21. Do you feel like your lower jaw is being pushed back when you bite your teeth together?

No

Yes

22. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

No

Yes

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

No

Yes

24. Are your teeth becoming more crooked, crowded, or overlapped?

No

Yes

25. Are your teeth developing spaces or becoming more loose?

No

Yes

26. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

No

Yes

27. Do you place your tongue between your teeth or close your teeth against your tongue?

No

Yes

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

No

Yes

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

No

Yes

30. Do you have any problems with sleep? (i.e. restlessness), wake up with a headache or an awareness of your teeth?

No

Yes

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

No

Yes

SMILE CHARACTERISTICS

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

No

Yes

33. Have you ever whitened (bleached) your teeth?

No

Yes

34. Have you ever felt uncomfortable or self-conscious about the appearance of your teeth?

No

Yes

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

No

Yes

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Contact Us

(403) 294-1077
info@alpinedentalcare.ca
180 9 St NE #100, Calgary, AB T2E 0P4, Canada

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Services

Children’s Dentistry
Emergency Dental Care
Restorative Dentistry
Same-Day Dentistry
Cosmetic Dentistry

Hours of Operation

Monday 7:00am - 2:30pm
Tuesday 7:00am - 4:00pm
Wednesday 7:00am - 7:00pm
Thursday 7:00am - 7:00pm
Friday 7:30am - 4:00pm
Saturday (Twice Monthly) 8:00am - 4:00pm
Sunday Closed

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