Patient Questionnaire

    Patient Details

    Emergency Contact Name:
    Emergency Contact Tel:

    Your Referring Dentist


    Medical History

    Your Medical History:

    What is your current health: GoodFairPoor

    Are you experiencing any pain or discomfort at this time? YesNo

    Please indicate on a scale of 1-5 the level of pain you are experiencing:
    1 (Mild)2345 (Extreme)

    Please select any of the following you have had in the past or at present:
    Heart ConditionHeart MurmurArtificial Heart ValveHigh Blood PressureRheumatic FeverBlood TransfusionLung DiseaseAsthma or Hay FeverKidney TroubleDiabetesThyroid DiseaseHepatitis or Liver DiseaseCancer or TumourRadiation/ChemotherapySTDsEpilepsy or SeizuresArtificial JointHIV Infection

    Do you have any health issues not listed above? YesNo
    If yes, please explain:

    Are you presently taking any medicine or drugs? YesNo
    If yes, please list:

    Are you allergic to any medicine, drug, or other substance? YesNo
    If yes, please list:

    Have you ever been hospitalised or had surgery? YesNo

    Have you ever had a reaction to local anesthetic? YesNo

    Have you ever had prolonged or unusual bleeding? YesNo

    Have you ever had illness following dental treatment? YesNo

    Have you ever had an injury or trauma to your face or jaw? YesNo

    Do you smoke or use smokeless tobacco? YesNo

    Are you nervous or concerned about having dental work done? YesNo

    Women: Are you pregnant now? YesNo
    If so, when is the due date:

    To the best of my knowledge, all of the preceding answers are true and correct. If I have any change in my health, or if my medications change, I will inform the dentist at the next appointment.

    Human Verification

    Please type the code above: