Patient Questionnaire

1
Reason for Visit?* This field is required.
2
Who Referred You to Us?
3
Patient Name* This field is required.
First Name
Last Name
4
Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Home Phone Number
Area Code
Phone Number
6
Mobile Phone Number
Area Code
Phone Number
7
Email Address* This field is required.
example@example.com
8
Preferred Method of Contact(may choose more than 1)
Home Phone
Mobile Phone
Email Address
9
Date of Birth* This field is required.
Type in date or use calendar to set date
Month
Day
Year
10
Gender* This field is required.
Male
Female
11
Social Security Number
12
Emergency Contact Name* This field is required.
First Name
Last Name
13
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
14
Who will be responsible for your account?
Self
Father
Mother
Spouse
Other
15
Name of Guarantor
First Name
Last Name
16
Guarantor's Date of Birth
Type in date or use calendar to set date
Month
Day
Year
17
Guarantor's Social Security Number
18
Guarantor Address(only complete address if different than Patient's address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Guarantor Employer
20
Do you have Dental Insurance?* This field is required.
YESNO
21
Dental Insurance Company Name
22
Dental Insurance Member ID Number
23
Dental Insurance Group Number
24
What is your height? (in inches)* This field is required.
height in inches (ex. 5'4" would be 64)
25
What is your weight? (in lbs)* This field is required.
weight in lbs.
26
Have there been any changes in your general health in the past year?* This field is required.
YESNO
27
Check any respiratory conditions listed below that you have* This field is required.(may choose more than 1)
Asthma
Sleep Apnea
Emphysema
Bronchitis
Pneumonia
Tuberculosis
Shortness of breath
Home Oxygen
None
28
Check any cardiac conditions listed below that you have* This field is required.(may choose more than 1)
High blood pressure
High cholesterol
Heart attack
Chest pain
Heart murmur
Irregular heart beat
Artificial heart valve
Rheumatic fever
Endocarditis
None
29
Check any musculoskeletal conditions listed below that you have* This field is required.(may choose more than 1)
Arthritis
Artificial joint
Chronic back pain
Weakness
Fibromyalgia
None
30
Check any liver conditions listed below that you have* This field is required.(may choose more than 1)
Cirrhosis
Hepatitis
None
31
Check any gastrointestinal conditions listed below that you have* This field is required.(may choose more than 1)
Acid reflux
Nausea/vomiting
Stomach ulcers
Hiatal hernia
None
32
Check any renal/endocrine conditions listed below that you have* This field is required.(may choose more than 1)
Kidney disease
Diabetes
Thyroid disease
Pituitary disease
Steroid use
None
33
Check any neurologic conditions listed below that you have* This field is required.(may choose more than 1)
Stroke
Paralysis
Seizures
Numbness/tingling
None
34
Check any psychiatric conditions listed below that you have* This field is required.(may choose more than 1)
Autism
Asperger's syndrome
Depression
Psychiatric disease
None
35
Check any additional conditions listed below that you have* This field is required.(may choose more than 1)
Cancer
Radiation
Chemotherapy
Bleeding disorder
Sickle cell
Osteoporosis
HIV/AIDS
Glaucoma
None
36
Please list any medical conditions you have not referenced previously(click NEXT if no additional conditions to add)
0/50
37
Have you had any prior Surgeries?* This field is required.
YESNO
38
Please list any prior Surgeries* This field is required.(we will discuss surgery detail at time of consult, type of procedure is all that is necessary)
0/50
39
Do you take any Medications or Supplements?* This field is required.
YESNO
40
Please list any Medications you are taking* This field is required.
0/50
41
Do you have any Allergies?* This field is required.
YESNO
42
Please list any Food or Medication Allergies you have* This field is required.
0/50
43
Have you ever taken or are currently taking a bone building medication, such as Fosamax, Actonel, Boniva, Reclast, or Prolia?* This field is required.
YESNO
44
Have you or a family member ever had any problems with anesthesia?* This field is required.
YESNO
45
Have you ever had any bleeding problems following surgery?* This field is required.
YESNO
46
Are you pregnant or think you may be pregnant?* This field is required.
YESNO
47
Have you used or currently use illegal drugs?* This field is required.
YESNO
48
Do you smoke cigarettes?* This field is required.
YESNO
49
Which best describes how much you smoke?* This field is required.
a few cigarettes per day
a half pack per day
one pack per day
more than 1 pack per day
50
Do you smoke marijuana?* This field is required.
YESNO
51
Do you drink alcohol?* This field is required.
YESNO
52
Which best describes how much alcohol you drink?
"I rarely drink."
"I only drink socially."
"I have 1-2 drinks per week."
"I have 3-5 drinks per week."
"I drink more than 5 drinks per week."
53
Are you in a pain contract?* This field is required.
YESNO
54
Do you see a dentist regularly?* This field is required.
YESNO
55
Date of last dental exam
Put 1st day of the month if exact day unknown
Month
Day
Year
56
Do your gums bleed when you brush your teeth?* This field is required.
YESNO
57
Do you grind or clench your teeth?* This field is required.
YESNO
58
Have you ever had problems with your jaw joints?* This field is required.
YESNO
59
Do you have frequent toothaches?* This field is required.
YESNO
60
During dental cleanings or xrays, do you easily gag?* This field is required.
YESNO
61
Have you ever had facial swelling that resolved with antibiotics?* This field is required.
YESNO
62
Have you ever been hospitalized because of a dental infection?* This field is required.
YESNO
63
Have you ever worn braces?* This field is required.
YESNO
64
Do you have a denture or partial dentures?* This field is required.
YESNO
Should be Empty: