Medical Questionnaire

Confidential Patient Information

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
















YesNo







Same as aboveOther person





Medical History




  1. YesNo

  2. YesNo

  3. YesNo

  4. YesNo
  5. Respiratory diseaseRheumatic feverScarlet feverShortness of breathThyroid problemsKidney problemsOsteoporosisHigh blood pressureLow blood pressureAbnormal bleedingNervous problemsBlood disordersVenereal diseaseArtificial jointsHepatitisAnemiaSinusArthritis
    DiabetesCancerPacemakerHerpesStrokeUlcerEpilepsyAsthmaHeart MurmurAids or HIV positiveTuberculosisLiver problemsHeart diseaseDizzy spellsChest painGeneral allergiesDiseases of eyes, ears, nose or throat

Dental History


  1. YesNo

  2. YesNo


  3. YesNo

  4. YesNo

  5. YesNo

  6. YesNo

  7. YesNo

  8. YesNo

  9. Loose teethSensitive teethEaracheHeadacheSpaced or crooked teethBleeding gumsBad breathe
    Neck painUnexplained nose bleedsUnsatisfactory denturesSore gumsPopping or clicking in the jaw jointsMissing teethGagging


Consent

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.