Online Health QuestionnaireFirst-time patients, please fill out and submit your health information form online, prior to your first visit!The questions marked (Â *Â ) are mandatoryOnline Health Questionnaire Registration InformationThe 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.Name * Name First First Last Last Prefers to be called Salutation * Dr. Mr. Mrs Ms Miss The patient is an: AdultChildAdult under guardianship Name of Guardian Address * City * Providence Home Phone * Business Phone Cell Phone Email Date of Birth * Age Sex * Male FemaleAre other family members patients at our office? * Yes No How did you hear about our office? * Medical PriorityThis information will enable us to make any essential contacts. Family Physician Phone Medical Specialist Phone In case of emergency, please contact Phone DENTAL VISITReason for visit? Examination Emergency Other If choose Other, please explain Is there a dental problem you would like treated immediately? Medical History1. Are you being treated for any medical condition at present or within the past two years? * Yes No If YES, please explain: Physician Phone Have you been hospitalized in past two years? Yes No When was your last visit to a Physician? Have you recently, or are you presently, taking any presricption or non-prescription drugs, incl. herbal remedies? Yes No Please list any/all prescription or non-prescription drug Have you ever reacted adversely to any of the following?:Penicillin * Yes NoAspirin * Yes NoCodeine * Yes NoLocal anaesthetic (freezing) * Yes No Other * Have you ever been advised against taking any specific type of medications? Have you ever reacted adversely to any of the following?:Asthma * Yes NoHay Fever * Yes NoFood Allergies * Yes NoMetal or Latex Allergies * Yes NoSkin Rashes * Yes NoHives * Yes No Any other allergic condition? Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? * Yes No If so, explain Is there a family history of Diabetes, Cancer or Heart Disease? * Yes NoDo you bleed EXCESSIVELY from a cut or injury, or bruise easily? * Yes NoDo your ankles, feet or hands swell? * Yes No Has your weight, appetite or energy level changed dramatically recently? * Yes NoDo you follow a special diet, or are you on a diet pill therapy? * Yes NoDo you experience shortness of breath or chest pain when taking a walk or climbing stairs? * Yes NoHave you tested HIV positive? * Yes NoDo you have FREQUENT SEVERE headaches, earaches, ear/throat infections? * Yes NoHave you ever had any injury or surgery to your face or jaws? * Yes NoDo you wear eyeglasses or contact lenses? * Yes NoDo you have any hearing difficulties? * Yes NoDo you smoke or use any other form of tobacco? * Yes NoAre you wearing the transdermal nicotine patch? * Yes NoAre you alcohol and/or drug dependent? * Yes Noand, Have you received treatment? Yes NoINDICATE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD:A.I.D.S. * Yes NoAnemia * Yes NoAngina pectoris * Yes NoARTHRITIS/rheumatism * Yes NoArtificial heart valve * Yes NoArtificial joints(hip, knee) * Yes NoBlood disorders * Yes NoBronchitis * Yes NoCancer * Yes NoCirculation problems * Yes NoCortisone/steroid * Yes NoCrohn's disease * Yes NoDiabetes * Yes NoEmphysema * Yes NoEpilepsy or seizures * Yes NoFainting or dizzy spells * Yes NoGlandular disorders * Yes NoGlaucoma * Yes NoHead/neck injuries * Yes NoHeart disease or attack * Yes NoHear murmur * Yes NoHeart pacemaker * Yes NoHeart rhytm disorder * Yes NoHeart surgery * Yes NoHepatisis A B C * Yes NoHerpes * Yes NoHigh/Low blood pressure * Yes NoHodgkins disease * Yes NoHype (HYPO) Glycemia * Yes NoHypertension * Yes NoInflamatory bowel disease * Yes NoJaundice * Yes NoKidney disease * Yes NoLiver disease * Yes NoLung disease * Yes NoLupus * Yes NoGlaucoma * Yes NoMalignant Hyperthermia * Yes NoMental/nervous disorder * Yes NoMitral valve prolapse * Yes NoOrgan transplant/medical implant * Yes NoPsychiatric treatment * Yes NoRadiation treatment/chemotherapy * Yes NoScarlet fever - Rheumatic fever * Yes NoSickle cell disease * Yes NoSinus trouble * Yes NoStomach/intestinal problems/Ulcers * Yes NoStroke * Yes NoThyroid disease * Yes NoTuberculosis * Yes NoVeneral disease * Yes No Other Women OnlyAre you pregnant or suspect you may be? * Yes NoAre you breast feeding? * Yes NoHealth QuestionsNote: it is important that any change in your health status be reported to our office. Do you currently have, or have you had in the past, any disease, condition or problem not listed above? Is there anything else about your health we should be made aware of? Do you wish to speak privately to the doctor about any problem or medical condition? Dental HistoryNote: 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? * Yes No If YES, explain: Date of your last dental visit? Last dental cleaning? Last x-rays? Have you been seeing a dentists regularly? * Yes NoHave you ever had any of the following?Periodontal Treatment (treatment of gum) Yes NoOrthodontic Treatment (to straighten or realign teeth) Yes NoA bite plate or any other appliance? Yes NoA bite plate or any other appliance? Yes NoYour bite adjusted or teeth ground? Yes NoDo your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums? Yes No If you answered YES to the last question, who performed the surgery? When Are you being followed up by a dental specialist? Are there any growths or sore spots in your mouth? Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?) Yes NoHave you noticed any loose teeth, or, do you suffer from pain or swelling of your gums? Yes NoDoes food catch between your teeth? Yes NoAre there any of your teeth sensitive to heat, cold, sweets or pressure? Yes NoHave you been advised to take antibiotics before a dental appointment? Yes NoDo you use dental floss, proxabrush or stimundents? Yes No How often? How often do you brush your teeth? Do you feel you have a bad breath? * Have you experience any of the following jaw problems:Popping / clicking in your jaw joints? Yes NoPain in your jaw joints, around your ear, or side of your face? Yes NoDifficulty in opening or closing? Yes NoPain when teeth are clenched? Yes NoPain or difficulty while chewing? Yes NoDo you have any of the following habits?Clenching or grinding your teeth while awake or asleep? Yes NoBiting your cheeks or lips? Yes NoMouth breathing while awake or asleep? Yes NoPlacing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)? Yes No and, What would you like to see changed? 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 Patient Parent Legal Guardian If GUARDIAN, full name: If you are human, leave this field blank. Signup
