(403) 225-1991
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(403) 225-1991
Why Choose Us
Dental Fees
Dental Insurance
FAQs
Health & Safety
Canyon and the Community
Services
Family Dentistry
Children’s Dentistry
Emergency Dentistry
Dental Hygiene & Teeth Cleanings
Root Canal Therapy
Orthodontics
Invisalign
6 Month Smiles
TMJ/TMD Therapy
Cosmetic Dentistry
Zoom Teeth Whitening
Porcelain Veneers
Cosmetic Tooth Bonding
Botox®
Restorative Dentistry
Dental Crowns
Dental Bridges
White Fillings
Oral Surgery
Tooth Extractions
Dental Implants
Wisdom Teeth Extractions
New Patients
New Patient Form
Team
Meet the Dentists
Dental Hygienists Team
Dental Assistant Team
Administration Team
Appointments
Education
Products
Contact
Book Now
Welcome to Canyon Dental Centre
"
*
" indicates required fields
PROFILE
Name
*
First
Last
Referred by
How would you rate the condition of your mouth?
*
Excellent
Good
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Poor
Previous Dentist
How long have you been a patient?
Date of most recent dental exam
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Date of most recent x-rays
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Date of most recent treatment
Day
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2019
2018
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2014
2013
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I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PERSONAL HISTORY
Are you fearful of dental treatment?
*
YES
NO
How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience?
*
YES
NO
Please add further details
Have you ever had complications from past dental treatment?
*
YES
NO
Please add further details
Have you ever had trouble getting numb or had any reactions to local anesthetic?
*
YES
NO
Please add further details
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
*
YES
NO
Please add further details
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
YES
NO
Please add further details
GUM AND BONE
Do your gums bleed or are they painful when brushing or flossing?
*
YES
NO
Please add further details
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
*
YES
NO
Please add further details
Have you ever noticed an unpleasant taste or odor in your mouth?
*
YES
NO
Please add further details
Is there anyone with a history of periodontal disease in your family?
*
YES
NO
Please add further details
Have you ever experienced gum recession?
*
YES
NO
Please add further details
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
*
YES
NO
Please add further details
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
*
YES
NO
Please add further details
TOOTH STRUCTURE
Have you had any cavities within the past 3 years?
*
YES
NO
Please add further details
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
*
YES
NO
Please add further details
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
*
YES
NO
Please add further details
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
*
YES
NO
Please add further details
Do you have grooves or notches on your teeth near the gum line?
*
YES
NO
Please add further details
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
YES
NO
Please add further details
Do you frequently get food caught between any teeth?
*
YES
NO
Please add further details
BITE AND JAW JOINT
Do you have problems with your jaw joint?
*
(pain, sounds, limited opening, locking, popping)
YES
NO
Please add further details
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
*
YES
NO
Please add further details
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
*
YES
NO
Please add further details
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
*
YES
NO
Please add further details
Are your teeth becoming more crooked, crowded, or overlapped?
*
YES
NO
Please add further details
Are your teeth developing spaces or becoming more loose?
*
YES
NO
Please add further details
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
*
YES
NO
Please add further details
Do you place your tongue between your teeth or close your teeth against your tongue?
*
YES
NO
Please add further details
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
YES
NO
Please add further details
Do you clench or grind your teeth together in the daytime or make them sore?
*
YES
NO
Please add further details
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
*
YES
NO
Please add further details
Do you wear or have you ever worn a bite appliance?
*
YES
NO
Please add further details
SMILE CHARACTERISTICS
Is there anything about the appearance of your teeth that you would like to change?
*
(shape, color, size)
YES
NO
Please add further details
Have you ever whitened (bleached) your teeth?
*
YES
NO
Please add further details
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
YES
NO
Please add further details
Have you been disappointed with the appearance of previous dental work?
*
YES
NO
Please add further details
ARE YOU INTERESTED IN OR HAVE YOU EVER CONSIDERED
Please select all that apply
Implants
Invisalign®
Orthodontics
Cosmetic Dentistry
Nitrous Sedation
Cosmetic Botox®
Whitening
Night Guard
Patient's Signature
From all of us at Canyon Dental Centre, we look forward to seeing you soon.
We look forward to hearing from you soon!
Call us at
(403) 225-1991
to book an appointment!
Book Online Today
Call Now
Why Choose Us
Dental Fees
Dental Insurance
FAQs
Health & Safety
Canyon and the Community
Services
Family Dentistry
Children’s Dentistry
Emergency Dentistry
Dental Hygiene & Teeth Cleanings
Root Canal Therapy
Orthodontics
Invisalign
6 Month Smiles
TMJ/TMD Therapy
Cosmetic Dentistry
Zoom Teeth Whitening
Porcelain Veneers
Cosmetic Tooth Bonding
Botox®
Restorative Dentistry
Dental Crowns
Dental Bridges
White Fillings
Oral Surgery
Tooth Extractions
Dental Implants
Wisdom Teeth Extractions
New Patients
New Patient Form
Team
Meet the Dentists
Dental Hygienists Team
Dental Assistant Team
Administration Team
Appointments
Education
Products
Contact
×