LONDON, ON

Contact Us

Medical Questionnaire

Doctors

ABOUT US

TESTIMONIALS

FAQ’S

GET IN TOUCH

    Patient Contact Information

    Patient Other Information

    Gender:

    Where did you hear about our practice?

    Insurance Information

    What type of insurance do you have?*

    Do you have secondary insurance?*

    Dental History

    Dental Concerns

    Are you having pain or discomfort at this time? *

    Do you feel nervous about having dental treatment? *

    Have you ever had a bad experience in a dental office? *

    Have you had a problem with freezing? *

    Do you have any problems with your jaw? *

    Do you have a severe gag reflex? *

    Medical History

    If you have health conditions involving any part of your body, this may have a relationship with your dental health and could influence the type of dental care and the way we administer your sedation. You are helping us provide you with the best possible care by completing this questionnaire as carefully as possible.

    Have you ever had sedation in a dental office?

    Oral Sedation *

    Nitrous Oxide (laughing gas) *

    IV sedation *

    Sleep Dentistry (general anaesthesia) *

    If yes, were you satisfied with the sedation level? *

    Do you have or does anyone in your family have a form of muscular dystrophy? *

    Do you have, or have you had radiation therapy? *

    Do you have, or have you had chemotherapy? *

    Have you been treated by a physician in the last year? *

    Have you been hospitalized or had an operation that required a general anaesthesia? *

    Have you or any member of your family had an adverse reaction to an anaesthetic?*

    Medical Conditions

    Past and Current Conditions (check all that apply to you, now or in the past)

    Cardiovascular

    Were you ever told by your family doctor that you had a heart condition?*

    Do you have high blood pressure?*

    Have you ever had a heart attack?*

    Do you have chest pain with physical activity?*

    Do you have congestive heart failure?*

    Do you have heart palpitation?*

    Were you ever told you had a heart murmur?*

    Pulmonary

    Have you been diagnosed with a lung disease?*

    Do you have asthma?*

    Do you smoke cigarettes?*

    Do you suffer from sleep apnea?*

    Endocrine

    Do you have diabetes?*

    Do you have problems with your Thyroid gland?*

    Have you taken Steroid pills in the last year?*

    Other Conditions

    Rheumatic fever*

    Stroke*

    Excessive shortness of breath*

    Tendency to faint when stressed*

    Epilepsy or Convulsion*

    Cancer*

    Bleeding problems*

    Anaemia*

    Low blood sugar*

    Chronic fatigue syndrome*

    Fibromyalgia*

    Stomach ulcer*

    Frequent heartburn*

    Glaucoma*

    Motion sickness*

    Limitation in neck movement*

    Limitation in mouth opening*

    Depression*

    Anxiety Disorder*

    Autism Spectrum Disorder*

    Other Mental Disease*

    Contagious diseases*

    Hepatitis*

    HIV/AIDS*

    Liver problems*

    Kidney problems*

    Drug addiction*

    Medical History Continued

    Do you take recreational drugs?*

    Do you drink alcohol every day?*

    Are you allergic, or have you had any unusual reaction to any of the following?

    Penicillin*

    Other antibiotics*

    Codeine*

    Narcotics*

    Sulfa drugs*

    Sulfites*

    Local Anaesthetics*

    Seasonal*

    Animal*

    Food*

    Prostheses

    Do you have any artificial joints (knee or hip for example)?*

    Have you ever had a heart valve replacement?*

    Do you wear dentures (partial or complete)?*

    Do you wear contact lenses?*

    Women only: Is there a possibility you could be pregnant?*