Health Questionnaire

If this is your first time choosing Argyle Associates for your oral surgery in Ottawa, here’s what you can expect. Your first visit will be a consultation. This is your chance to meet your surgeon, learn more about your surgery and ask any questions about the procedure or fees. This will also be our chance to review your medical and dental history and take any x-rays needed. The purpose of this appointment is to make sure you’re feeling comfortable about your procedure and to ensure our team is fully prepared for the day of the surgery. This consultation usually lasts between 45 and 75 mins, please arrive 15 mins early to check-in.

"*" indicates required fields

The following information is confidential and for our records only.

Last Name*

Last Name

First Name*

First Name

Middle Initial

Marital Status*

Marital Status

Gender*

Gender

Today's Date*

MM slash DD slash YYYY

Date of Birth*

MM slash DD slash YYYY

Age*

Height*

Weight*

Address*

Apt

City*

Postal Code

Phone

Home Phone*

Work Phone

Cell Phone*

E-mail address

Emergency contact*

Emergency Contact Phone*

Referred by*

Occupation

Firm

Name of Family Physician

Name of Dentist

Do you live alone?*

Yes

Are you seeing a dental specialist other than us? (Orthodontist, Periodontist, Endodontist)*

Yes

Name of specialist

FOR PRESCRIPTION PURPOSES / EN RAISON DE PRESCRIPTIONS

OHIP

Exp.

Driver's License

HEALTH QUESTIONNAIRE

1. Are you in good health?*

Yes

Please Explain

2. Are you presently having pain or difficulty with your teeth or your jaw?*

Yes

Please Explain

3. Are you on any medications?*

Yes

Please List

4. Do you have any known allergies?*

Yes

Please List

5. Do you Smoke or Vape?*

Yes

How many per day ?

How many per year?

6. Have you ever had abnormal bleeding tendencies?*

Yes

Please Explain

Have you been treated in the past for:

7. Diabetes*

Yes

Please Explain

8. Heart Trouble*

Yes

Please Explain

9. Epilepsy*

Yes

Please Explain

10. Kidney Disease*

Yes

Please Explain

11. Rheumatic Fever*

Yes

Have you ever been told that you've suffered heart damage from the rheumatic fever?

12. Hepatitis*

Yes

Please Explain

13. Asthma*

Yes

Please Explain

14. HIV+*

Yes

Please Explain

15. Hypertension*

Yes

Please Explain

Have you ever been diagnosed with:

16. Lung Problems (Asthma, Emphysema, Bronchitis, other)*

Yes

Please Explain

17. Stroke*

Yes

Please Explain

18. Problems with your immune system (HIV/AIDS, Steroid Use, Lupus)*

Yes

Please Explain

19. Cancer (Chemotherapy, Radiation Therapy)*

Yes

Please Explain

20. Osteoporosis*

Yes

Please Explain

21. Other

22. Do you snore?*

Yes

Please Explain

23. Do you stop breathing when you sleep?*

Yes

Please Explain

24. Have you ever been diagnosed with Sleep Apnea?*

Yes

Please Explain

25. Do you use a CPAP machine?*

Yes

Please Explain

26. Do you currently, or have you in the past, used prescription narcotics, street drugs or marijuana recreationally?*

Yes

27. If yes: what / how often / when ?

28. Do you consume cannabis (in any form - smoke, edibles, etc.)?*

Yes

29. If yes, how many grams per day?

30. Are you now or have you ever been treated for drug addiction or alcoholism?*

Yes

Please Explain

31. Are you subject to neurological disorders? (Multiple Sclerosis, Parkinson's Disease, Alzheimer's Disease, etc.)?*

Yes

Please Explain

32. Have you ever had general anaesthetic?*

Yes

Please Explain

33. Have you or your family ever had complications during an anesthetic?*

Yes

Please Explain

34. Do you have dizziness or shortness of breath?*

Yes

Please Explain

35. Is there anything special about you or your family's physical condition that should be called to the doctor's attention?*

Yes

Please Explain

36. Are you pregnant?*

Yes

Please Explain

37. Do you wear contact lenses?*

Yes

Please Explain

38. Are you highly afraid of needles?*

Yes

Please Explain

39. How did you hear about us?*

Google

Facebook

Dentist

Mail

Friend / Family

Other

Health Questionnaire

The following information is confidential and for our records only.

FOR PRESCRIPTION PURPOSES / EN RAISON DE PRESCRIPTIONS

HEALTH QUESTIONNAIRE

Have you been treated in the past for:

Have you ever been diagnosed with:

We will have one of our trained professionals get back to you as soon as possible.

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