• Seaforth Oral Surgery

    Seaforth Oral Surgery

    Confidential Health Questionnaire

  • IDENTIFICATION

  • Date of birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • CONTACT

  • Format: (000) 000-0000.

  • TODAY'S VISIT

  • HEALTH HISTORY

    Oral surgeons provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your oral surgeon provide you with the best possible care by informing him of these conditions

  • GENERAL HEALTH

    Please check the appropriate response:

  • Are you generally in good health?*
  • Have there been any changes in your health in the past year?*
  • Do you have, or have you ever had (only select those that apply)
    Rows

  • TREATMENTS

  • Have you been treated by a physician in the past year?*

  • HOSPITALIZATION

  • Have you ever been hospitalized or had an operation?*

  • MEDICATION

  • Have you been taking any medication in the past year (including birth control pills)?*

  • ALLERGIES

  • Are you allergic,or have you had any unusual reaction to any of the following? (Please only select those that apply to you)
    Rows

  • PROSTHESIS

  • Do you have, or have you ever had, any of the following? (Please only select those that apply to you)
    Rows

  • WOMEN ONLY

  • Are you pregnant?
  • Expected date of deliveryDate
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you nursing?

  • PAST AND CURRENT CONDITIONS

  • Do you currently have Osteoporosis?*
  • Are you currently taking, or have you ever taken, medications for the treatment of osteoporosis?
  • Please check all that apply to you, now or in the past (Please only select those that apply to you)
    Rows

  • NOTES

  • SIGNATURE

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: