FIRST VISIT QUESTIONNAIRE

Please fill in all the required fields indicated by an asterisk(*).
Please note that a response may take up to 1 business day.

First Name
Last Name
DOB mm/dd/year
Address
City
Province
Postal Code
Email
Home Phone
Work Phone
Mobile Phone
Referred by
Physician
Occupation
Employer
Account Rep
Insurance Co.
Group #, ID #
MEDICAL HISTORY
Have you ever had a serious illness or are you under the care of a physician now?
Have you had a medical examination in the last year?
Do you use any medicine now?
Do you ever have asthma, hay fever, hives or skin rash?
Has any member of your family had diabetes?
Have you ever experienced any unusual reaction to any of the following?
Do you bruise easily or bleed abnormally?
Do you have any blood disorder such as anaemia (thin blood)?
Have you ever had any injury, surgery or X-ray therapy to your face or jaws?
Do you have a tendency to faint?
Do you have frequent severe headaches?

Are you pregnant? (Which month?)
Have you ever had any of the following diseases?
Control/Command click to select more than one
Do you have any disease, condition or problem not listed above that you think the doctor should know about?
Do you have a prosthetic implant?
DENTAL HISTORY
Have you had a regular dental examination (annually) in the past year?
Do you have any oral habits such as clenching, grinding your teeth or nail biting?
Have you ever had tooth brushing instruction?
Have you ever had instruction in using dental floss?
What concerns you most about your dental health?
Notes or Comments

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