Medical Questionnaire

Confidential Patient Information

The following information is required by the Dentist to assist in proper diagnosis and treatment.

 Yes No

 Same as above Other person

Medical History

  1.  Yes No

  2.  Yes No

  3.  Yes No

  4.  Yes No
  5.  Respiratory disease Rheumatic fever Scarlet fever Shortness of breath Thyroid problems Kidney problems Osteoporosis High blood pressure Low blood pressure Abnormal bleeding Nervous problems Blood disorders Venereal disease Artificial joints Hepatitis Anemia Sinus Arthritis
     Diabetes Cancer Pacemaker Herpes Stroke Ulcer Epilepsy Asthma Heart Murmur Aids or HIV positive Tuberculosis Liver problems Heart disease Dizzy spells Chest pain General allergies Diseases of eyes, ears, nose or throat

Dental History

  1.  Yes No

  2.  Yes No

  3.  Yes No

  4.  Yes No

  5.  Yes No

  6.  Yes No

  7.  Yes No

  8.  Yes No

  9.  Loose teeth Sensitive teeth Earache Headache Spaced or crooked teeth Bleeding gums Bad breathe
     Neck pain Unexplained nose bleeds Unsatisfactory dentures Sore gums Popping or clicking in the jaw joints Missing teeth Gagging


 I agree

Financial Information

All accounts payable when services are rendered. Interest charged on overdue accounts.

 I authorize release, to my insurance company/plan administrator information contained in claims submitted electronically.