Online Health Questionnaire

First-time patients, please fill out and submit your health information form online, prior to your first visit!

The questions marked ( * ) are mandatory

Online Health Questionnaire

Registration Information

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are commited to collecting, using and disclosing this information responsibly.

Are other family members patients at our office?

Medical Priority

This information will enable us to make any essential contacts.


Reason for visit?

Medical History

1. Are you being treated for any medical condition at present or within the past two years?
Have you been hospitalized in past two years?
Have you recently, or are you presently, taking any presricption or non-prescription drugs, incl. herbal remedies?

Have you ever reacted adversely to any of the following?:

Local anaesthetic (freezing)

Have you ever reacted adversely to any of the following?:

Hay Fever
Food Allergies
Metal or Latex Allergies
Skin Rashes
Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?
Is there a family history of Diabetes, Cancer or Heart Disease?
Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?
Do your ankles, feet or hands swell?
Has your weight, appetite or energy level changed dramatically recently?
Do you follow a special diet, or are you on a diet pill therapy?
Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
Have you tested HIV positive?
Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?
Have you ever had any injury or surgery to your face or jaws?
Do you wear eyeglasses or contact lenses?
Do you have any hearing difficulties?
Do you smoke or use any other form of tobacco?
Are you wearing the transdermal nicotine patch?
Are you alcohol and/or drug dependent?
and, Have you received treatment?


Angina pectoris
Artificial heart valve
Artificial joints(hip, knee)
Blood disorders
Circulation problems
Crohn's disease
Epilepsy or seizures
Fainting or dizzy spells
Glandular disorders
Head/neck injuries
Heart disease or attack
Hear murmur
Heart pacemaker
Heart rhytm disorder
Heart surgery
Hepatisis A B C
High/Low blood pressure
Hodgkins disease
Hype (HYPO) Glycemia
Inflamatory bowel disease
Kidney disease
Liver disease
Lung disease
Malignant Hyperthermia
Mental/nervous disorder
Mitral valve prolapse
Organ transplant/medical implant
Psychiatric treatment
Radiation treatment/chemotherapy
Scarlet fever - Rheumatic fever
Sickle cell disease
Sinus trouble
Stomach/intestinal problems/Ulcers
Thyroid disease
Veneral disease

Women Only

Are you pregnant or suspect you may be?
Are you breast feeding?

Health Questions

Note: it is important that any change in your health status be reported to our office.

Dental History

Note: it is important that any change in your health status be reported to our office.

Is there a dental problem you would like treated immediately?
Have you been seeing a dentists regularly?

Have you ever had any of the following?

Periodontal Treatment (treatment of gum)
Orthodontic Treatment (to straighten or realign teeth)
A bite plate or any other appliance?
A bite plate or any other appliance?
Your bite adjusted or teeth ground?
Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?
Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?)
Have you noticed any loose teeth, or, do you suffer from pain or swelling of your gums?
Does food catch between your teeth?
Are there any of your teeth sensitive to heat, cold, sweets or pressure?
Have you been advised to take antibiotics before a dental appointment?
Do you use dental floss, proxabrush or stimundents?

Have you experience any of the following jaw problems:

Popping / clicking in your jaw joints?
Pain in your jaw joints, around your ear, or side of your face?
Difficulty in opening or closing?
Pain when teeth are clenched?
Pain or difficulty while chewing?

Do you have any of the following habits?

Clenching or grinding your teeth while awake or asleep?
Biting your cheeks or lips?
Mouth breathing while awake or asleep?
Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?

General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowlingly omitted any information. Should there be any change in either my health status or any other information I have provided, I will advise thsi dental office. I authorize the dentists to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependants is mine, and I assume responsibility for fees associated with these services.
Signature (to be signed in the office)

I am