Are you receiving any medical treatment at this present time?
YesNo
Please list all your medications taken:
Have you experienced allergies or unusual effects from any tablets, injections, or anaesthetic?
YesNo
Details:
Have you ever had any of the following?
WOMEN: Are you pregnant? If so, when is your due date:
Details of person to contact in an emergency:
Dental Questionnaire
Are you a smoker?
Name and location of last dentist? Approximate date of last dental visit:
Do you have dental pain or a dental problem at present?
Do you become anxious or uncomfortable when having dental treatment?
YesNo
Do you brush and floss daily?
YesNo
Do you grind or clench your teeth?
YesNo
Do you experience any sensitivity with hot/cold?
YesNo
Is there anything with your teeth that you are unhappy about?
YesNo
If Yes, details:
How would you rate your smile on a scale of 1 to 10? (10 being perfect)
Is there anything else you would like the dentist to know?
YesNo
If Yes, details:
I understand that if I fail to give 48 hours notice to cancel my appointment, that a fee may be charged. I agree to be responsible for payment of all services rendered on my behalf, and on the behalf of my dependents understand that this payment is due at the time of service unless other arrangements have been made.
