PERIOPARTNERS MEDICAL HISTORY QUESTIONNAIRE

MEDICAL HISTORY QUESTIONNAIRE

The following information is required to enable us to provide you with the best possible dental care. All information is strictly protected by patient-doctor confidentiality. One of the dental staff will review the questions and explain any that you do not understand. Please fill in the entire form.
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
CONTACT INFORMATION
Phone Number (Home):
Format: (000) 000-0000.
Phone Number (Cell):
Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code
Email:*
example@example.com
Address (Business):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Business):
Please enter a valid phone number.Format: (000) 000-0000.
Occupation:
Who referred you to our office?:*
IN CASE OF EMERGENCY
Contact Name:
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Name of Family Doctor:
Doctor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor Phone:
Please enter a valid phone number.Format: (000) 000-0000.
(1) Name of Medical Specialist:
Area of Specialty:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
(2) Name of Medical Specialist:
Area of Specialty:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE INFORMATION

Primary Insurance
Insurance Carrier:
Policy Holder:
Date of Birth:

MonthDayYear
Date
Group/Plan No:
Cert No/ID No:
Secondary Insurance
Secondary Insurance Carrier:
Policy Holder:
Date of Birth:

MonthDayYear
Date
Group/Plan No:
Cert No/ID No:
QUESTIONNAIRE

Please fill in to the best of your knowledge.
YesNo
2. Who is your general dentist?*
3. How long have you been seeing your general dentist?*
4. How often do you see your general dentist and/or hygienist for checkups and cleanings?*
5. When was your last cleaning?*
6. Do you know why you were referred to our office?*
7. How many times per day do you brush your teeth? *
7b. Do you use a manual or an electric toothbrush?*
8. How many times per day do you floss your teeth?*
9. Do you use any other dental hygiene tools at home? For example: waterpik, interproximal brush etc.*
10. How would you rate your overall dental health? On a scale of 1-10 where 1 is the worst and 10 is the best.*
YesNoNot sure/maybe
11b. If yes, does this bother you from an esthetic or sensitivity standpoint?
LowMediumHigh
YesNoNot sure/maybe
YesNoNot sure/maybe
14b. If yes, do you know your more recent HbA1c value?
YesNo
YesNo
YesNo
15d. If you smoke, vape or use chewing tobacco, are you interested in quitting?
YesNoNot sure/maybe
YesNoNot sure/maybe
YesNoNot sure/maybe
17b. If so, why?
18. When was your last medical check-up?*
YesNoNot sure/maybe
19b. If yes, please explain:
YesNoNot sure/maybe
20b. If yes, please list:
YesNoNot sure/maybe
21b. If yes, please list:*
YesNoNot sure/maybe
22b. If yes, please explain:*
YesNoNot sure/maybe
YesNoNot sure/maybe
24b. If yes, please list:
YesNoNot sure/maybe
25b. If yes, please list and on what date:
YesNoNot sure/maybe
26b. If yes, please list:
YesNoNot sure/maybe
27b. If yes, please list:
YesNoNot sure/maybe
28b. If yes, please list:
Chest pain/anginaHeart attackStrokeShortness of breathPacemakerLung diseaseTuberculosisCancerSteroid therapyDiabetesStomach ulcersArthritisSeizures (epilepsy)Kidney diseaseThyroid diseaseDiet pill therapyDrug/alcohol dependency
YesNoNot sure/maybe
30b. If yes, please list:
YesNoNot sure/maybe
31b. If yes, please list:
YesNoNot sure/maybe
32b. What is the expected delivery date?
YesNoNot sure/maybe
I Certify that I have read, and I understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, affiliated entities, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
Please use your mouse or finger to sign below.*

Clear
(Signature)
Date:*

MonthDayYear
Date
PERSONAL INFORMATION CONSENT FORM
We are committed to protecting the privacy of your personal information and using all personal information in a responsible and professional manner.

PERSONAL INFORMATION COLLECTED
• Names, residence and business addresses, email addresses, cell, residence and business telephone numbers.
• Financial information such as dental insurance information, third party dental provider information and payment transaction slips if you are paying by credit or debit card.
• Pertinent medical and dental histories and clinical photographs.

HOW WE USE THE INFORMATION COLLECTED
Personal information is used to open and update patient files, to contact patients for follow-up treatment, process dental benefit claims and to send patients informational material about our practice.

Financial information is used to process payments for our services, to process claims for third party providers and dental insurance companies and collect unpaid accounts.

Medical and dental information is used to diagnose and safely and appropriately treat dental conditions.

WHOM WE MIGHT DISCLOSE PERSONAL INFORMATION TO
Insurance companies and third party dental providers for approval, re-imbursement or payment of dental services.

To other dentists, dental offices or health professionals where we are seeking a second opinion and the patient has consented to obtaining a second opinion or where we are referring the patient for diagnosis and treatment.

To other dentists, dental offices or health professionals who have asked us, with the consent of the patient, for a second opinion or who have referred the patient to our office for diagnosis and treatment.

To legal firms or other parties with the consent of the patient. To the Alberta Dental Association and College, the regulatory board of dentists, who may inspect our records and interview our staff as part of its regulatory activities in the public interest.

If we consider selling all or part of our dental practice the potential qualified purchaser may be granted access to patient information as part of the due diligence process to verify information necessary for the potential sale. If this occurs we will take steps to ensure the non-disclosure of your personal information.

I consent to the collection, use and disclosure of my personal information as indicated above.
Date:*

MonthDayYear
Date
Print Name:*

First NameLast Name
Please use your mouse or finger to sign below.*

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(Signature)
PATIENT ACKNOWLEDGEMENTS

CANCELLATION POLICY
It is the practice of our office to see all our patients on an appointment basis. We respect your time and make every effort to remain on schedule. We ask that you extend the same courtesy to us. If you are unable to keep your appointment, we request that you notify us at least 1 week prior to your appointment. Patients who fail to provide us with one-week cancellation notification time may be charged a missed appointment fee of $250.

If you have any questions or require clarification, please contact our office.

I have read and understood the Cancellation Policy as outlined herein. I agree to the terms described and assume full liability for any fees charged should I fail to abide by these short notice requirements.
Date:*

MonthDayYear
Date
Please use your mouse or finger to sign below.*

Clear
(Signature)
Should be Empty:

MEDICAL HISTORY QUESTIONNAIRE

CONTACT INFORMATION

IN CASE OF EMERGENCY

INSURANCE INFORMATION

QUESTIONNAIRE

PERSONAL INFORMATION CONSENT FORM

PATIENT ACKNOWLEDGEMENTS