• Seaforth Oral Surgery

    Seaforth Oral Surgery

    Confidential Health Questionnaire

  • IDENTIFICATION

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  • 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?*
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  • 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

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  • PROSTHESIS

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  • WOMEN ONLY

  • Are you pregnant?
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  • 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?
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  • NOTES

  • SIGNATURE

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