Health Questionnaire Form

Patient Information

Name *Required

Full Name:

Personal Address

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

Contact Information

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

General Dentist

Full Name
Street Address
Address Line 2
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
Have you noticed any loose teeth or change in your bite? *Required
Does food get caught between your teeth? *Required

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
Thyroid Problems
Chronic Cough
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Hepatitis A (infectious)
Contact Lenses
Hepatitis B (serum)
Veneral Disease
Cold Sores/Fever Blisters
Blood Transfusion
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