Health Questionnaire Form

Patient Information

Name *Required

Prefix
Full Name:

Personal Address

Street Address *Required
Address Line 2 *Required
City *Required
State / Province / Region
ZIP / Post Code
Country
Date of Birth *Required
Occupation *Required

Contact Information

Home
Work
Mobile Number
Email *Required
Best Number to Call *Required
Referral From
 
Emergency Contact Name *Required
Emergency Contact Mobile *Required

General Dentist

Full Name
Practice
Street Address
Address Line 2
City
Country
General Dentist Contact Phone
 
Would you like us to contact your dentist?
We recommend routine dental exams and hygiene visits
If you do not have a regular Dentist or Hygienist would you like us to provide these services?
What is the reason for your visit today *Required

Dates of your last:

Dental Visit
Dental Cleaning
Full Mouth X-rays
What was done during your last dental visit?
How often do you have dental examinations
How often do you brush your teeth? *Required
How often do you floss? *Required
What other dental aids do you use? (Inter plak, toothpicks, etc_)
Do you have any dental problems now? *Required
If yes, please describe

Have you ever had:

Are any of your teeth sensitive to:

Have you noticed any mouth odors or bad tastes? *Required
Have you had plate(s) or mouth guard(s)? *Required
Do your gums bleed or hurt? *Required
Have your parents had gum disease or tooth loss? *Required
Yes
Have you noticed any loose teeth or change in your bite? *Required
Does food get caught between your teeth? *Required
Yes

Do you:

Do you feel nervous about treatment? *Required
If yes, what is your biggest concern
Have you been under the care of a medical doctor during the past 2 years? *Required
If yes, for what?
Have you taken any medication or drugs during the past 2 years? *Required
Please list any medication, drugs, or pills you may be taking now
Have you taken any prescriptions for weight loss (diet pills)? *Required

If yes, did you take any of the following?

If yes to any of the above, did you have a medical examination for heart issues? *Required
Are you aware of having an allergic or adverse reaction to any medications or substances? *Required
If yes, please list:
Have you been a patient in hospital during the past 5 years? *Required
If yes, please list:

Indicate which of the following you have had or have at present:

Artificial Joints (hip, knee, etc)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (infectious)
Contact Lenses
 AIDS
Hepatitis B (serum)
Veneral Disease
 HIV+
Cold Sores/Fever Blisters
Blood Transfusion
 Haemophilia
Sickle Cell Disease
Bruise Easily
  Liver Disease
Yellow Jaundice
Neurological Disorders
 Epilepsy or Seizures
 Fainting or Dizzy Spells
 Nervous / Anxious
 Psychiatric / Psycological Care
Do you have or have you had any disease, condition, or problem not listed? *Required
If yes, please list:

For Women

Are you pregnant? 
If yes, how many months? (Please enter a number from 0 to 9)
Are you Breast Feeding

Terms and Conditions *Required

I understand that the above information is necessary to provide me with dental care in a safe and efficient manner_ I have answered all questions to the best of my knowledge_Should further information be needed, you have my permission to ask the respective health care provider or agency who may release such information to you_ I will notify thedoctor/dentist of any change in my health or medication.

 I agree to the terms and conditions