Medical Questionnaire

Please answer all questions below. By skipping questions you will not be allowed to submit at the end.
There are "No", "None of the above", or "Other" answers to every question. 

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1. Please enter the code given to you in your email:

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2. Do you consider yourself to be in good health?

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3. Who do you see as your Medical Doctor?

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4. Are you now or have you been under a physician's care within the past year?
(Example: Emergency room visit, broken bone, chronic illness, etc.)

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5. Have you had any hospitalizations or surgeries in the past 5 years?

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6. Women: Are you currently pregnant or trying to become pregnant?

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7. Due to differences in medication prescriptions and their reactions to an individuals biology we need to know the following information:

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8. Are you taking any medications including over the counter pain pills and/or herbal supplements and/or vitamins?

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9. Have you ever had an unusual reaction or are you allergic to any of the following drugs:

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10. Have you ever taken Phen-Fen or similar appetite suppressants?

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11. Are you currently or have you in the past been treated for Cancer?

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12. Have you ever taken any of the following drugs prescribed to decrease the resorption of bone as in Osteoporosis or any drugs for Metastatic Bone Cancer?

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13. Do you or have you ever had any heart or blood conditions?

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14. Have you ever been told you have a heart murmur?

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15. Do you require antibiotic pre-medication for a heart condition or artificial valve?

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16. Have you been diagnosed with high blood pressure?

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17. Do you bleed or bruise easily?

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18. Have you ever been diagnosed for any of the following:

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19. Are you subject to fainting?

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20. Have you ever had a severe reaction to dental treatment or local anesthetics?

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21. Are you allergic to any local anesthetics?

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22. Do you have any other allergies? (Including food)

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23. Have you ever had a nervous breakdown or undergone psychiatric treatment?

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24. Have you ever been treated for or received counseling for use of alcohol and/or prescription drugs?

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25. Have you ever or currently vape or smoke/use tobacco products?

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26. Do you consume alcohol?

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27. When was the last time you visited the dentist?

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28. Are any of your teeth or parts of your mouth causing you pain or discomfort? 

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29. Do you feel that your teeth are affecting your general health in any way?

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30. Do your gums bleed easily?

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31. Does your diet consist of a lot of sugary foods or liquids?

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32. If you could change anything about your smile, what would it be? (Check all that apply)

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33. Have you been diagnosed with or experienced any of the following symptoms:

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34. Do you snore or have you been told you snore?

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35. Have you been diagnosed with Sleep Apnea?

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36. Have you had a sleep study or been told to undergo a sleep study?

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37. Do you have fear or anxiety when going to the dentist?

By submitting this form, I certify that the answers to the health questions are accurate and correct to the best of my knowledge. Since a change of medical condition or medications can affect dental treatment, I understand the importance of and agree to notify the dentist of any changes at any subsequent visit.

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