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. Question Title 1. Please enter the code given to you in your email: Question Title 2. Do you consider yourself to be in good health? Yes No Question Title 3. Who do you see as your Medical Doctor? I don't have a general doctor at this time. Doctors Full Name/Office Name Question Title 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.) No If yes, specify condition being treated and date of last exam: Question Title 5. Have you had any hospitalizations or surgeries in the past 5 years? No If yes, specify condition being treated and date of the exam/hospitalization: Question Title 6. Women: Are you currently pregnant or trying to become pregnant? Yes No I am Male Question Title 7. Due to differences in medication prescriptions and their reactions to an individuals biology we need to know the following information: I am biologically Male I am biologically Female I would prefer to let the doctor know in a private setting Question Title 8. Are you taking any medications including over the counter pain pills and/or herbal supplements and/or vitamins? Yes No Please list ALL medications, vitamins and supplements (and dosage of each) you are currently taking: Question Title 9. Have you ever had an unusual reaction or are you allergic to any of the following drugs: Penicillin Aspirin Acetaminophen Ibuprofen Codeine Barbiturates Sulfa Drugs None of the above Other (please specify) Question Title 10. Have you ever taken Phen-Fen or similar appetite suppressants? No If yes, have you seen your physician or cardiologist for a cardiac evaluation? Question Title 11. Are you currently or have you in the past been treated for Cancer? No If yes, please list all medications/treatments you were prescribed during your care: Question Title 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? Fosamax Actonel Boniva None of the above Other (please specify) Question Title 13. Do you or have you ever had any heart or blood conditions? No If yes, please specify: Question Title 14. Have you ever been told you have a heart murmur? No If yes, please specify: Question Title 15. Do you require antibiotic pre-medication for a heart condition or artificial valve? No If yes, please specify: Question Title 16. Have you been diagnosed with high blood pressure? No If yes, please specify: Question Title 17. Do you bleed or bruise easily? No If yes, please specify: Question Title 18. Have you ever been diagnosed for any of the following: Rheumatic Fever HIV Positive or AIDS Hepatitis or Liver Disease Asthma Blood Disorder Diabetes Tuberculosis Heart Attack Rhuematism Venereal Disease Arthritis Kidney Disease Immune System Disorders None of the Above Other (please specify) Question Title 19. Are you subject to fainting? No If yes, please specify: Question Title 20. Have you ever had a severe reaction to dental treatment or local anesthetics? No If yes, please specify: Question Title 21. Are you allergic to any local anesthetics? No If yes, please specify: Question Title 22. Do you have any other allergies? (Including food) Latex Seasonal I don't have any other allergies Other (please specify) Question Title 23. Have you ever had a nervous breakdown or undergone psychiatric treatment? No If yes, please specify: Question Title 24. Have you ever been treated for or received counseling for use of alcohol and/or prescription drugs? No If yes, please specify: Question Title 25. Have you ever or currently vape or smoke/use tobacco products? No If yes, how often? How many packs a day? Question Title 26. Do you consume alcohol? No If yes, how often? Question Title 27. When was the last time you visited the dentist? 2-6 months ago 6 months to a year 1-2 Years 2-5 years Less than 10 years 10+ years I have never been to the dentist Question Title 28. Are any of your teeth or parts of your mouth causing you pain or discomfort? No If yes, please specify: Question Title 29. Do you feel that your teeth are affecting your general health in any way? No If yes, please specify: Question Title 30. Do your gums bleed easily? No If yes, please specify: Question Title 31. Does your diet consist of a lot of sugary foods or liquids? Yes No Comments Question Title 32. If you could change anything about your smile, what would it be? (Check all that apply) Whiter Smile Straighter Teeth Healthier Gums Missing Teeth Tooth Shape Tooth Sensitivity Tooth Color/Stains Other (please specify) Question Title 33. Have you been diagnosed with or experienced any of the following symptoms: Grinding teeth at night Waking up with a headache Waking up with a sore jaw Clenching of teeth during the day and/or at night Strong gag reflex Acid reflux Insomnia Restless leg syndrome Trouble sleeping/staying asleep at night Fibromyalgia Jaw pain or Temporomandibular joint dysfunction (TMJ) Tension in the face or jaws None of the Above Question Title 34. Do you snore or have you been told you snore? No If yes, please specify: Question Title 35. Have you been diagnosed with Sleep Apnea? No If yes, do you wear a CPAP or have you in the past? Have you been told to? Question Title 36. Have you had a sleep study or been told to undergo a sleep study? No Yes Question Title 37. Do you use any over the counter medication for headache pain or as a sleeping aid? No Yes I have in the past Question Title 38. Is it easy for you to get to sleep or stay asleep? Yes No Occasionally Question Title 39. Do you wake rested in the morning? Yes No Question Title 40. Do you experience sounds like popping or clicking in the jaw joints? Yes No Occasionally Question Title 41. Do you have fear or anxiety when going to the dentist? Not at all A little bit I have a lot of anxiety about the dentist My spouse would have to drag me by the leg to get me there 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. Submit