Medical / Dental Questionnaire

Filling out form

Patient Health Form

Name*
MM slash DD slash YYYY
Address, City, Postal Code*
Please indicate if you have any of the following conditions for which you have been treated*
Are you in good health?*
Do you have any history of major illness?*
Are you taking any drugs or medication?*
Are you allergic or sensitive to any drugs?*
Do you need to take antibiotics before dental work?*
Do you smoke?*
Are there any other medical conditions we should know about?*
Have you ever injured your face, mouth, teeth?*
Have you ever sucked a thumb or finger?*
Do you have any difficulty chewing foods?*
Do you play any contact sports?*
Was your last dental check-up within 6 months?*
Do you have any jaw joint (TMJ) problems?*
MM slash DD slash YYYY