Medical History Questionnaire

1
Welcome to Oxford Dental! Let's start with your first name...* This field is required.
First Name
2
{FirstName}, what's your last Name?* This field is required.
Last Name
3
Date of Birth * This field is required.
Date
Year
Month
Day
4
Sex* This field is required.
Male
Female
Transgender Male
Transgender Female
Unspecified
5
{FirstName}, what's your Cell Phone Number?
Area Code
Phone Number
6
Email* This field is required.
example@example.com
7
Mailing Address * This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
How Did You Hear About Us?
Internet/Search Engine
Friend Referal
Social Media
Referal
TV/Radio
Third-Party Review
Other
9
When was your last dental visit? * This field is required.
Date
Year
Month
Day
10
{FirstName}, Do you have Dental Insurance? * This field is required.
YESNO
11
Insurance Carrier Name
12
Policy Holder Name
13
Policy Holder Date of Birth
Date
Year
Month
Day
14
Plan, Policy or Group #
15
ID or Certificate #
16
Occupation
17
Employer Name ** This field is required.
18
Employer Phone Number
19
Secondary Insurance? If so, Name of ins holder / carrier / plan / id #
20
{FirstName}, please let us know the reason for your appointment?* This field is required.
21
Emergency Contact * This field is required.
First Name
Last Name
22
Emergency Contact Email * This field is required.
example@example.com
23
Emergency Contact Phone Number * This field is required.
Area Code
Phone Number
24
Name of Family Doctor
25
When was your last medical checkup?
Date
Year
Month
Day
26
Are you being treated for any medical condition at the present time or have you been treated within the past year? * This field is required.
YESNO
27
What medical condition are you currently being treated for?
28
Has there been any change in your general health in the past year?* This field is required.
YESNO
29
{FirstName}, could you please specify what has changed?
30
Have you had any surgeries in the past five years?* This field is required.
YESNO
31
{FirstName}, could you please provide details about the surgery?
32
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? * This field is required.
YESNO
33
{FirstName}, could you please list the medications, non-prescription drugs, or herbal supplements you are taking?
34
Do you have any allergies?* This field is required.
YESNO
35
{FirstName}, could you please specify the allergies you have?
36
Have you ever had a peculiar or adverse reaction to any medicines or injections? * This field is required.
YESNO
37
{FirstName}, could you please explain the reaction you experienced?
38
Do you have or have you ever had asthma?* This field is required.
YESNO
39
Do you have or have you ever had any heart or blood pressure problems?
YESNO
40
{FirstName}, could you please explain the heart condition?
41
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? * This field is required.
YESNO
42
Do you have a prosthetic or artificial joint?* This field is required.
YESNO
43
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV Infection, radiotherapy, chemotherapy? * This field is required.
YESNO
44
{FirstName}, could you please explain the condition affecting your immune system?
45
Have you ever had hepatitis (A,B,C or another form) jaundice or liver disease? * This field is required.
YESNO
46
Type a Do you have a bleeding problem or bleeding disorder?* This field is required.
YESNO
47
Have you ever been hospitalized for any illness or operations? * This field is required.
YESNO
48
{FirstName}, could you please explain the illness?
49
Do you have or have you had any of the following?* This field is required.
chest pain, angina
heart attack
stroke
shortness of breath
rheumatic fever
mitral valve prolapse
heart murmur
glaucoma
pacemaker
lung disease
tuberculosis
cancer
herpes
steroid therapy
diabetes
stomach ulcers
arthritis
seizures (epilepsy)
kidney disease
thyroid disease
drug/alcohol dependency
osteoporosis medication
none of the listed apply
50
Are there any conditions or diseases not listed in the previous question that you have or have had?* This field is required.
YESNO
51
Could you please specify the disease?
52
Are there any diseases or medical problems that run in your family?* This field is required.
YESNO
53
Please specify the medical problem.
54
Do you smoke, chew or use tobacco products?
YESNO
55
Are you nervous during dental treatment?* This field is required.
YESNO
56
Are you breastfeeding or pregnant?* This field is required.
YESNO
57
Finally, {FirstName}, any Additional Questions or Comments?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: