Dental Clinic Health Questionnaire

Last, First and Middle Name

Email Address

Date of Birth

Mailing Address

City/Province

Postal Code

Home Phone Number

Cell Phone Number

Name of Emergency Contact

Phone Number of Emergency Contact

Have you been examined/treated by a medical doctor in the past year? Have you been examined/treated by a medical doctor in the past year? Yes No

Name of Doctor, NP, or Alternative Practitioner

Phone Number

Have you ever been seriously ill or hospitalized? Have you ever been seriously ill or hospitalized? Yes No

Have you ever had abnormal bleeding with trauma, extraction, or surgery? Have you ever had abnormal bleeding with trauma, extraction, or surgery? Yes No

Are you currently taking any medication or non-prescription drugs/supplements? Are you currently taking any medication or non-prescription drugs/supplements? Yes No

Please list medications here

Do you have any allergies? Do you have any allergies? Yes No

Please list allergies here

Have you ever been pre-medicated for dental treatment? Have you ever been pre-medicated for dental treatment? Yes No

Please check if you have, or have had, any of the following Please check if you have, or have had, any of the following Rheumatic Fever Heart Murmer Congenital Heart Condition Heart Attack Arteriosclerosis Stroke or TIA Angina Pectoris Blood Pressure Problems Heart Trouble Lung or Breathing Problems Stomach/Intestinal Troubles Hepatitis or Jaundice Diabetes Blood Disorder Pacemaker/Artificial Valve Infectious/Communicable Disease HIV positive test Covid-19 positive test Tumours or Growths Nervous/Mental Troubles Epilepsy Tobacco Use Non-prescription drug use Thyroid Condition Arthritis Inflammatory/Rheumatic Condition Cortisone/Steroid Treatment Hives/Skin Rashes Hay Fever Allergies Unusual Reaction to Drugs Trouble with Dental Anesthesia Severe Headaches Chronic Sinus Trouble Chronic Sore Throat Chronic Ear Ache Trouble Hearing Hearing Aid Prolonged Bleeding After Injury Bruise Easily Shortness of Breath Chest Pains Swollen Ankles Heart Palpitations Extra Pillows for Sleep, Sleep Apnea Persistent Cough Recent Change in Appetite Difficulty Swallowing Frequent Indigestion, Vomiting Gastroesophageal reflux Feel thirsty most of the time Urinate more than 6 times a day Painful, Swollen Joints Numb/Prickling Sensations History of Broken Bones Osteoporosis Tendency to Faint Seizures or Convulsions History of Family Disease Other

Please list any other conditions or concerns

Please check if you are a woman and have any of the following Please check if you are a woman and have any of the following Pregnant Past Menopause

Name of Previous Dentist

Phone Number

Date of last Dental Visit

Have you had annual regular dental care in the past? Have you had annual regular dental care in the past? Yes No

Please check if you have, or have had, any of the following Please check if you have, or have had, any of the following Bleeding gums Sensitivity to cold Sensitivity to hot Teeth grinding Teeth clenching Nail biting Sores or lumps in mouth Injury to face or jaw Missing fillings Unpleasant dental experience Reaction to local anesthetic Local anesthetic didn’t work well Allergic reaction to rubber dam Claustrophobia Gagging Need extra TLC Need extra cushioning Panic attack Root canal treatment Denture or partial denture Orthodontic treatment Treatment by dental specialist Surgery in your mouth

Mouth surgery details

How often do you brush your teeth?

How often do you floss?

What other oral hygiene products or devices do you use?

Are you satisfied with the function and appearance of your teeth? Are you satisfied with the function and appearance of your teeth? Yes No

Have you had instruction in using dental floss? Have you had instruction in using dental floss? Yes No

What dental conditions concern you now?

Additional information that you think may be helpful