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EMERGENCY CONTACT NEW PATIENT

Services
Lectures & Workshops
Smile Consult
Digital Smile Design
Meet Our Doctors
- Dr. Paresh Shah
- Dr. Neil Wilson
Meet Our Team
Contact

(204) 837-4517

Book Appointment

Call Today: (204) 837-4517

Book Appointment

Services

Digital Dentistry
Dental Implants
Aesthetics
Comprehensive Care

LECTURES & WORKSHOPS

Digital Smile Design

Meet Our Doctors

Dr. Paresh Shah
Dr. Neil Wilson

New Patient

Thank you for choosing Westwood Dental! Please download the forms below, fill them out, save it and send them to admin.westwood@mymts.net or you may print them out and bring them into the office during your visit. If you have any questions, please call our office at 204-837-4517.

DENTAL HISTORY

Reffered by How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

Previous Dentist How long have you been a patient? Month/Years

Date of most recent dental exam Date of most recent x-rays

Date of most recent treatment (other than a cleaning)

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:

YES NO

PERSONAL HISTORY

1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) []

Yes

No

2. Have you had an unfavorable dental experience?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

6. Have you had any teeth removed?

Yes

No

SMILE CHARACTERISTICS

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

BITE AND JAW JOINT

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

Yes

No

12. Do you / would you have any problems chewing gum?

Yes

No

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

Yes

No

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

Yes

No

15. Are your teeth crowding or developing spaces?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

TOOTH STRUCTURE

21. Have you had any cavities within the past 3 years?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

27. Do you get food caught between any teeth?

Yes

No

GUM AND BONE

28. Do your gums bleed when brushing or flossing?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

32. Have you ever experienced gum recession?

Yes

No

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

Yes

No

34. Have you experienced a burning sensation in your mouth?

Yes

No

Patient’s Signature

Clear

OK

Date

Doctor’s Signature

Clear

OK

Date

6-3421 Portage Ave.
Winnipeg, MB R3K2C9

admin.westwood@mymts.net

© 2020. Dr. Paresh Shah