Confidential Health Questionnaire

Your privacy is very important to us. We are committed to earning your trust by safeguarding your personal information. All the information you provide to us is securely stored and is kept strictly confidential.

IDENTIFICATION

First Name

Last Name

Date of birth

Please enter the date in this format: dd/mm/yyyy

Phone Number

Phone (Cell)

Phone Number (Work)

Street Address

City

Province/State

Postal Code/ZIP Code

E-mail address

Name of your family doctor

Referred by

INSURANCE

Do you have dental insurance ?

Type of Insurance

Insurance Company name:

Primary Card Holder:

Policy / Contract Number:

Identification / Certificate Number:

Card holder name:

Relationship with patient:

Date of birth

Please enter the date in this format: dd/mm/yyyy

University Name:

id:

CONTACT

Person to contact in case of emergency:

Telephone

TODAY'S VISIT

Reason for your visit to our office today:

HEALTH HISTORY

Dentists provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your dentist provide you with the best possible care by informing him of these conditions.

GENERAL

Please check the appropriate response

HEALTH

Are you generally in good health?
YesNo

If no, please explain

Have there been any changes in your health in the past year?
YesNo

If yes, please specify

Do you have, or have you ever had:

Radiotherapy
YesNo

Chemotherapy
YesNo

Do you smoke?
YesNo

TREATMENT

Have you been treated by a physician in the past year?
YesNo

If yes, for what condition?

HOSPITALIZATION

Have you ever been hospitalized or had an operation?
YesNo

If yes, please describe

MEDICATION

Have you been taking any medication in the past year including birth control pills)?
YesNo

If yes, please list

ALLERGIES

Are you allergic, or have you had any unusual reaction to any of the following?

Penicillin
YesNo

Dental injection
YesNo

Other antibiotic
YesNo

Valium
YesNo

Aspirin
YesNo

Codeine
YesNo

General anesthesia
YesNo

Latex
YesNo

Sulfa drugs
YesNo

Other medications
YesNo

Other

PROSTHESES

Do you have, or have you ever had, any of the following?

Artificial joints
YesNo

Heart valve or a pacemaker
YesNo

Other prosthetic implants
YesNo

Removable dental appliance
YesNo

WOMEN ONLY

Are you pregnant?
YesNo

Expected date of delivery

Are you nursing?
YesNo

PAST AND CURRENT CONDITIONS

Please check all that apply to you, now or in the past:

Rheumatic feverEpilepsy, convulsionsDamaged heart valvesStrokeHeart murmurThyroid problemsHigh blood pressureDiabetesLow blood pressureLow blood sugarChest pain/anginaKidney problemsHeart attackDialysisIrregular heart beatSwollen ankles, arthritis or joint diseaseCardiac pacemakerStomach ulcersHeart surgeryContagious diseaseBronchitis, chronic coughAsthmaHay feverSnoring/sleep apneaHIV/AIDSSexually-transmitted diseasesProblems with your immune systemSlow wound healingDifficulty breathingCancerTuberculosisInfectious monoucleosisChronic fatigue, night sweatsBlood transfusionYou are on a special dietBruise easilyDrug abuseAlcohol abuseTendency to bleedHepatitis, jaundice or liver diseaseContact lensesEye disease/glaucomaGallbladder problemsMental health problemsTendency to faint

NOTES

DENTAL HISTORY

Last visit
0-6 months6-12 months12 months+

Treatment received

Have you previously had dental treatments such as:

Oral hygiene instructions
YesNo

Gum treatment
YesNo

Orthodontic treatment
YesNo

Root canal treatment
YesNo

Dental fillings
YesNo

Crown or/and bridge
YesNo

Partial or/and complete denture
YesNo

Surgical treatment or extraction
YesNo

Dental implants
YesNo

X-rays
YesNo

Others
YesNo

To be completed by patient

I, the undersigned, hereby declare that I have read, understood and answered the above medical/dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up as well as my registration on the recall list of the attending dentist(s). I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.

SIGNATURE

Date

contact@nuodental.com

514.861.6106