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Confidential Questionnaire
Date
First Name
Last Name
Street Address
City
Postal / Zip code
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Birthday
Age
Sex
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M
Relationship Status
Single
Married
Divorced
Widowed
Seperated
Telephone/Contact Info
Phone
Emergency Contact Name
Email
Emergency Contact Phone Number
Emergency Contact Relationship
Do you have any family members/friends that are patients of this office?
Yes
No
How did you hear about us?
Referral
Website
Social Media
Signage
Dental Insurance Primary Coverage
Name of Insured
Employer
Group or Policy No.
Date of Birth
Insurance Company
Certificate or ID No.
Dental Insurance Additional Coverage
Name of Insured
Employer
Group or Policy No.
Best Time to Contact You
Anytime
Days Only
Evenings
Weekends
Have you ever had any upsetting experience in a dental office or any complications during or following treatment or do you have any concerns?
Date of Birth
Insurance Company
Certificate or ID No.
Employer
Occupation
Dental History
When was your last dental visit?
Are you experiencing any dental pain?
Yes
No
Have you noticed any loose teeth or shifting?
Yes
No
Are any of your teeth sensitive to heat, cold, sweets or pressure?
Yes
No
How often do you brush your teeth?
Have you ever had periodontic (gum) treatment?
Yes
No
Do you have pain in your jaw joints, around your ear or side of your face?
Yes
No
Pain when teeth are clenched?
Yes
No
Do you clench or grind your teeth?
Yes
No
When were x-rays last taken?
Are there growths or sore spots in your mouth?
Yes
No
Does food get caught between your teeth?
Yes
No
Have you been advised to take antibiotics before a dental appointment?
Yes
No
Do you use dental floss, proxabrush or stimudents?
Yes
No
Do you feel that you have bad breath?
Yes
No
Any difficulty opening or closing your jaw?
Yes
No
Pain and/or difficulty chewing?
Yes
No
Are you happy with the appearance of your teeth?
Yes
No
What would you like to change?
Medical Information
Family Doctor
Weight
Are you currently under the care of your physician?
Yes
No
Phone
Height
When was your last medical check-up?
If yes, what are you being treated for?
Are you presently taking any drug or medication or have taken any in the last 6 months?
Yes
No
If so, which
Have you ever been hospitalized or have you ever had surgical intervention other than dental?
Yes
No
If yes, please explain
Are you presently taking any homeopathic products?
Yes
No
If so, which
Have you ever been diagnosed or treated for cancer?
Yes
No
If yes, please explain
Have you ever had heart problems such as angina, stroke, heart murmur or valvular problems
Yes
No
Do you smoke?
Yes
No
If yes, please explain
Is there anything concerning your health you wish to discuss privately with your dentist?o you smoke?
Yes
No
Are you allergic to or have you ever had reactions to:
Specific Foods
Antibiotics (Penicillin)
Iodine
Latex (Rubber)
Sedatives
Sulfa Drugs
Aspirin/Codeine
Local Anesthetics
Metals
Flavours (Mint)
Other
For Women Only
Are you pregnant or think you are pregnant?
Yes
No
Are you presently nursing?
Yes
No
Are you presently taking oral contraceptives?
Yes
No
Health History
Have you ever been treated for:
Heart Attack/Heart Disease
Shortness of Breath
Heart Murmur
Pacemaker
Mitral Valve prolapse
Steroid Therapy
Drug/Alcohol Dependency
Abnormal Blood Pressure (High/Low)
Rheumatic/Scarlet Fever
Tuberculosis/Any Lung Disease
Liver Disease (Hepatitis/Jaundice)
Arthritis or Joint Problems
Cancer
Blood Disorders
Anemia
Artificial Joints or Implants
Mental or Nervous Disease
Epilepsy (Seizures)
Stroke
Hay Fever/Allergies
Asthma
Multiple Sclerosis
Malignant Hyperthermia
AIDS/HIV Positive
Venereal Disease
Cerebral Palsy
Frequent Colds/Sinusitis
Stomach Ulcer
Hepatitis B or C
Fibromyalgia
Kidney Disease
Thyroid
Gall Bladder
Diabetes
Digestive Problems
Eye Problems/Cataracts
Skin Conditions/Psoriasis
Frequent Headaches
Osteoporosis Meds (Fosamax, Actonel)
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