SECURED AND CONFIDENTIAL MEDICAL QUESTIONNAIRE

Last Name:

First Name:

Gender:
MF

Address:

Apt:

City:

Postal Code:

Tel Home:

Cell:

Tel Work:

Date of Birth:

Day:

Month:

Year:

Email:

Who should we thank for referring you to our office ?

Dr:

Other:

What is the main reason for your visit?:

Do you have any dietary restrictions (special diet, personal or religious)?
If so, which ones?

Were you ever hospitalized or have you undergone surgery other than dental? If so, indicate which ones and when?

Surgery:

Year:

Surgery:

Year:

Surgery:

Year:

Please provide the information about your pharmacy.

Name:

Address:

Phone number:

Precautions:

What could we do to make your visit in our office as pleasant as possible?

Is there something about your smile that you dislike?

When was your last dental cleaning?

How often do you get your teeth cleaned at the dentist?

Have you ever had orthodontic treatment (braces, invisalign, etc.)?
YesNo

If yes: Last date of treatment

Have you had periodontal treatment in the past (gum graft, periodontitis, etc.)?
YesNo

Do you have any missing teeth other than your wisdom teeth?
YesNo

Do you have any dental implants?
YesNo

If yes: When

If yes: Dentist

How often do you brush your teeth?

Are you using a manual or an electric toothbrush?
Manual
Electric

Are you using floss, interdental brushes or waterpik for your interdental cleaning?
Floss
Interdental brushes
Waterpik

How often do you clean between your teeth?

Do your gums bleed?
YesNo

Do you have any oral pain?
YesNo

Do you have any loose or shifting teeth?
YesNo

If yes, which ?

Do you have a bad taste in your mouth?
YesNo

Do you have a bad breath?
YesNo

Does food often get stuck between your teeth?
YesNo

If yes, where ?

Do you have any sensibility to hot or cold?
Hot
Cold

Do you have any sensitivity when chewing hard foods?
YesNo

Do you breathe through your mouth?
YesNo

Do you clench or grind your teeth?
YesNo

Do you wear a night guard while you sleep?
YesNo

Do you suspect that you suffer from sleep apnea?
Yes(confirmed)MaybeNo

Who is your periodontist ?

I, the undersigned, hereby declare that I have read, understood and answered the above medical questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health.

Name:

Date: