This information will enable us to maintain communication with you
This information will enable us to make any essential contacts
Reason for today's visit:
Is there a dental problem you would like to treat immediately?
When was your last visit to a Physician?
When was your last complete physical examination?
List any prescription or non-prescription drugs, including herbal remedies, that you have recently, or are presently, taking:
Have you ever reacted adversely to any of the following medications or injections (Please check which apply)?:
Penicillin or other antibiotics
Please select the statements below that apply to you
I have been treated for a medical condition within the last two years
I have been hospitalized in the past
I have previously been advised against taking a specific type of medication
I smoke or use another form of tobacco
I wear a transdermal nicotine patch
I am alcohol and/or drug dependent
(Regarding the above) I am receiving treatment
I am taking blood thinners
Indicate which of the following you presently have or have ever had:
Sleep Disorder Questionnaire
Do you snore loudly?
Do you often feel tired, fatigued or sleepy during the day time?
Do you have or are being treated for high blood pressure?
Do you have a BMI over 35 (weight in kg, divide by height in meters, then divide again by height in meters)?
Neck circumference > 16 inches?
Are you male?
Please indicate which of these are barriers to moving forward with proposed treatment (ideal treatment):
Please indicate which of these you value the most in terms of you teeth and any treatment that is rendered:
What is the most important quality for you in a relationship with a doctor?
Are you the type of person who likes a lot of detailed information, or do you prefer more bottom line information?