Health Questionnaire

Surgeon
- Dr. Biewald
- Dr. Moghadam
- Dr. Butterfield
- Dr. Lee
- Dr. Irvine
- Dr. McGuire
Location
- Barrhaven
- Kanata
- Carling
- Orleans
The following information is confidential and for our records only.
Last Name*
Last Name
First Name*
First Name
Middle Initial*
Middle Initial
Marital Status*
Marital Status
Gender*
Gender
Today's Date*
Date of Birth*
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
- No
Are you seeing a dental specialist other than us? (Orthodontist, Periodontist, Endodontist)*
- Yes
- No
Name of specialist
FOR PRESCRIPTION PURPOSES / EN RAISON DE PRESCRIPTIONS
OHIP
Exp.
Or
Driver's License
HEALTH QUESTIONNAIRE
1. Are you in good health?*
- Yes
- No
Please Explain
2. Are you presently having pain or difficulty with your teeth or your jaw?*
- Yes
- No
Please Explain
3. Are you on any medications?*
- Yes
- No
Please List
4. Do you have any known allergies?*
- Yes
- No
Please List
5. Do you Smoke or Vape?*
- Yes
- No
How many per day ?
How many per year?
6. Have you ever had abnormal bleeding tendencies?*
- Yes
- No
Please Explain
Have you been treated in the past for:
7. Diabetes*
- Yes
- No
Please Explain
8. Heart Trouble*
- Yes
- No
Please Explain
9. Epilepsy*
- Yes
- No
Please Explain
10. Kidney Disease*
- Yes
- No
Please Explain
11. Rheumatic Fever*
- Yes
- No
Have you ever been told that you've suffered heart damage from the rheumatic fever?
12. Hepatitis*
- Yes
- No
Please Explain
13. Asthma*
- Yes
- No
Please Explain
14. HIV+*
- Yes
- No
Please Explain
15. Hypertension*
- Yes
- No
Please Explain
Have you ever been diagnosed with:
16. Lung Problems (Asthma, Emphysema, Bronchitis, other)*
- Yes
- No
Please Explain
17. Stroke*
- Yes
- No
Please Explain
18. Problems with your immune system (HIV/AIDS, Steroid Use, Lupus)*
- Yes
- No
Please Explain
19. Cancer (Chemotherapy, Radiation Therapy)*
- Yes
- No
Please Explain
20. Osteoporosis*
- Yes
- No
Please Explain
21. Other
22. Do you snore?*
- Yes
- No
Please Explain
23. Do you stop breathing when you sleep?*
- Yes
- No
Please Explain
24. Have you ever been diagnosed with Sleep Apnea?*
- Yes
- No
Please Explain
25. Do you use a CPAP machine?*
- Yes
- No
Please Explain
26. Do you currently, or have you in the past, used prescription narcotics, street drugs or marijuana recreationally?*
- Yes
- No
27. If yes: what / how often / when ?
28. Do you consume cannabis (in any form - smoke, edibles, etc.)?*
- Yes
- No
29. If yes, how many grams per day?
30. Are you now or have you ever been treated for drug addiction or alcoholism?*
- Yes
- No
Please Explain
31. Are you subject to neurological disorders? (Multiple Sclerosis, Parkinson's Disease, Alzheimer's Disease, etc.)?*
- Yes
- No
Please Explain
32. Have you ever had general anaesthetic?*
- Yes
- No
Please Explain
33. Have you or your family ever had complications during an anesthetic?*
- Yes
- No
Please Explain
34. Do you have dizziness or shortness of breath?*
- Yes
- No
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
- No
Please Explain
36. Are you pregnant?*
- Yes
- No
Please Explain
37. Do you wear contact lenses?*
- Yes
- No
Please Explain
38. Are you highly afraid of needles?*
- Yes
- No
Please Explain
39. How did you hear about us?*
- Google
- Facebook
- Dentist
- Mail
- Friend / Family
- Other

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Health Questionnaire

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: