Dental Clinic Health Questionnaire

All information is confidential and not shared without your consent. Insight into your medical and dental conditions will
allow us to treat you safely.

Prefer a printable form?

Have you been examined/treated by a medical doctor in the past year?

Have you ever been seriously ill or hospitalized?

Have you ever had abnormal bleeding with trauma, extraction, or surgery?

Are you currently taking any medication or non-prescription drugs/supplements?

Do you have any allergies?

Have you ever been pre-medicated for dental treatment?

Please check if you have, or have had, any of the following

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

Have you had annual regular dental care in the past?

Please check if you have, or have had, any of the following

Are you satisfied with the function and appearance of your teeth?

Have you had instruction in using dental floss?

12 + 3 =