Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do your gums bleed when you brush? *

Yes

No

Have you ever had orthodontic or orthotropic treatment(e.g., braces)? *

Yes

No

Have you had any periodontal (gum) treatment? *

Yes

No

Are your teeth sensitive to hot, cold, sweets, or pressure? *

Yes

No

Have you ever had an injury to your head, face, or jaws? *

Yes

No

Do you suffer from frequent headaches? *

Yes

No

Do you have earaches or neck pains? *

Yes

No

Do you have removable dental appliances? Implants? *

Yes

No

Are you nervous during dental treatment? *

Yes

No

Can you clean all of your teeth using your tongue? *

Yes

No

Not Sure

Are you being treated for any medical condition or have you been treated within the past year? *

Yes

No

Has there been any change in your general health in the past year? *

Yes

No

Have you ever been hospitalized for any illnesses or operations? *

Yes

No

Do you have a prosthetic or artificial joint (e.g., hip, knee)? *

Yes

No

Have you ever been advised to take antibiotics before dental treatment? *

Yes

No

Have you ever had a peculiar or adverse reaction, including allergies, to any medications or injections? *

Yes

No

Do you have any allergies to any foods or materials (e.g., latex or metals)? *

Yes

No

Do you have any other allergies(e.g., hay fever, animals)? *

Yes

No

Do you have a history of cancer? *

Yes

No

Do you have dry mouth? *

Yes

No

Ear or hearing problems? *

Yes

No

Eye problems (e.g., require corrective lenses, glaucoma)? *

Yes

No

Do you stay asleep all night? *

Yes

No

Do you feel refreshed in the morning? *

Yes

No

Maybe

Are you or could you be pregnant?

Yes

No

Are you breastfeeding?

Yes

No

Are you taking hormone replacement therapy?

Yes

No

Are you taking medications of any kind? Include prescribed drugs, over-the-counter medications (e.g., cold and flu remedy), and natural health products (e.g., vitamins, herbal, and diet supplements). If yes, please list. *

Yes

No

Cardiovascular diseases? If yes, specify below: *

Yes

No

Chest pains upon exertion? *

Yes

No

Shortness of breath? *

Yes

No

Asthma? *

Yes

No

Chronic bronchitis or emphysema? *

Yes

No

Sinus trouble or nasal congestion? *

Yes

No

Tuberculosis? *

Yes

No

A persistent cough for more than 3 weeks? *

Yes

No

Cough that produces blood? *

Yes

No

Malnutrition? *

Yes

No

Eating disorder? *

Yes

No

Dietary restrictions (self-imposed or doctor prescribed)? *

Yes

No

Night sweats? *

Yes

No

Slow healing or recurrent infections? *

Yes

No

Thyroid or parathyroid disease? *

Yes

No

Diabetes? If yes, indicate type: *

Yes

No

Hepatitis, jaundice, or liver disease? *

Yes

No

Difficulty swallowing? *

Yes

No

G.E. reflux/persistent heartburn? *

Yes

No

A stomach ulcer? *

Yes

No

Gall bladder problems? *

Yes

No

Kidney or bladder trouble? *

Yes

No

Excessive urination? *

Yes

No

Prolonged or abnormal bleeding with a simple cut or following surgery, extraction, or an accident? *

Yes

No

A blood transfusion? If yes, date: *

Yes

No

A tendency to bruise easily? *

Yes

No

Any blood disorder (e.g., anemia or hemophilia)? *

Yes

No

Systemic lupus erythematosus? *

Yes

No

Painful swollen joints or rheumatoid arthritis? *

Yes

No

HIV? *

Yes

No

Other diseases or conditions that affect your immune system (e.g.,sarcoidosis, Epstein-Barr,radiotherapy, chemotherapy,steroid therapy)? *

Yes

No

Have you ever had an antibiotic resistant infection (e.g.,MRSA)? *

Yes

No

A stroke? *

Yes

No

Convulsions or seizures(e.g., epilepsy)? *

Yes

No

Mental health disorders? *

Yes

No

Arthritis? *

Yes

No

Osteoporosis or osteopenia? *

Yes

No

Chronic pain? *

Yes

No

Do you smoke, chew or snort tobacco/cannabis products? *

Yes

No

Have you ever tried to quit?

Yes

No

N/A

Do you want to quit?

Yes

No

N/A

Do you have a drug or alcohol dependency? *

Yes

No

I am confirming the completed information is correct to the best of my knowledge.

Yes