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Health Questionnaire

Your smile is as unique as you are.

Online Fillable Form

"*" indicates required fields

The following information is confidential and for our records only.

Salutation*

Full Name*

Home Phone*

Cell Phone*

Date of Birth*

MM slash DD slash YYYY

Address*

Apt

City*

Postal Code*

Province*

In case of emergency, we should notify

Emergency contact name*

Emergency Contact Phone*

Emergency Contact Relationship*

Guardian Information (if applicable):

Name

Relationship

Phone

Name of Family Physician*

Family Physician Phone*

Medical specialist

Area of specialty

Phone #

Other medical specialist

Area of specialty

Phone #

Who referred you to our office?*

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand.

1. How often do you see the dentist/hygienist?*

3 months

4 months

6 months

9 months

12 months

Over 1 year

2. Do you have Pain? Where?

2b. Do you have Bleeding Gums? Where?

2c. Do you have Dental Implants? When Placed?

3. Have you ever had trauma to the jaw, mouth and/or teeth?*

Yes

If so where?

4. When was your last full medical exam with blood work?*

5. Have you ever been told to be pre-medicated prior to any dental treatment by a medical doctor/surgeon?*

Yes

6. Do you have or have you had any of the following:

Sleep Apenea*

Yes

Diabetes*

Type I

Type II

What is your A1C?

Thyroid disease*

Yes

Please Explain

Asthma, COPD, Emphysema*

Yes

Please Explain

Hypertension*

Yes

Please Explain

Heart attack*

Yes

When?

Pacemaker, stent*

Yes

When?

Chest pain/angina/Stroke*

Yes

When?

Arthritis (Rheumatoid or Osteo)*

Yes

Please Explain

Seizures*

Yes

Please Explain

Kidney disease*

Yes

Please Explain

Acid reflux*

Yes

Please Explain

Anxiety/depression*

Yes

Please Explain

Osteoporosis*

Yes

Please Explain

Bleeding problems*

Yes

Please Explain

Liver problems*

Yes

Please Explain

Drug/alcohol dependency*

Yes

Please Explain

Radiation*

Yes

When?

MM slash DD slash YYYY

Cancer... chemo*

Yes

When?

MM slash DD slash YYYY

Artificial or prosthetic joint (when was the surgery?)

Tuberculosis*

Yes

HIV/AIDS*

Yes

Hepatitis A, B, C*

Yes

Any therapies/conditions that could affect your immune system:

Are there any other medical conditions/diseases not listed that you have or have had?

7. Please list all prescription, non-prescription drugs or herbal supplements you are currently taking (with doses):

8. Do you have any allergies or side effects to:

Medication:

Seasonal, foods:

9. Have you ever been hospitalized for any major illnesses or surgeries? If yes, please list type and date.

10. Do you smoke cigarettes, cigars or use e-cigarettes?*

If yes to any of the above, how much?

Have you recently quit? When?

11. Do you consume alcohol?*

Yes

If yes, what type of alcohol and how many drinks per day?

12. Do you use recreational drugs? (marijuana, cocaine etc.)?*

If yes, what type of drug and how much per day?

13. Are you nervous during dental treatment?

Yes

14. For women: Are you breastfeeding or pregnant?

Yes

If pregnant, what is the expected delivery date?

MM slash DD slash YYYY

To the best of knowledge, the above information is correct:

Patient/Parent/Guardian:*

Date*

MM slash DD slash YYYY

Dentist signature:

Dentist signature date:

Smile with Confidence

Schedule Your Appointment Today!

Full periodontal services: implants, crown lengthening, gum grafts, surgical exposure, etc.

Location

Ottawa Periodontists
1335 Carling Avenue Suite 308
Ottawa, Ontario K1Z 8N8

Contact Us

Monday to Friday: 7:30am to 4:00pm
Telephone: 613-792-4658
Fax: 613-792-4970
info@ottawaperiodontist.com

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Health Questionnaire

Your smile is as unique as you are.

Online Fillable Form

The following information is confidential and for our records only.

Smile with Confidence

Location

Contact Us

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