BALA INSTITUTE OF ORAL SURGERY: HEALTH QUESTIONNAIRE UPDATE

BALA INSTITUTE OF ORAL SURGERY
15 PRESIDENTIAL BOULEVARD, SUITE 301 ⬧ BALA CYNWYD, PA 19004 (610) 667-6161 ⬧ WWW.BALASURGERY.COM
CONFIDENTIAL HEALTH QUESTIONNAIRE
Full Name*
FIRST, LAST
Date of Birth*

MonthDayYear
Date
Cell Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact*
Emergency Contact Phone Number*

Area CodePhone Number
General Dentist*
Dentist Phone Number

Area CodePhone Number
Wisdom TeethExtractionsDental ImplantsOral LesionsCysts or TumorsBiopsyPain (Oral/Facial)BiopsyFractured JawOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YESNO
If yes, please describe.
YESNO
If yes, please describe.
YESNO
If yes, duration.
YESNO
If yes, please list:
YESNO
If yes, please list:
YESNO
If yes, please list additional medications:
Additional medications:
Additional medications:
YESNO
AspirinAmoxicillinor other antibioticsCodeineor other narcoticsLatexLocalanestheticsNSAIDsSulfaOther
YESNO
YESNO
YESNO
If yes, please describe:
YESNO
HepatitisTuberculosis (T.B.)AIDS
Pharmacy Name
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Street
City
State
12. Do you currently have or have you ever had any of the following conditions?
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Vaping ProductsTobaccoAlcoholRecreational DrugsIn recovery: If so, please specify (e.g., substance use, alcohol, etc.) in OtherOther
If you answered "Yes" to any of the above questions, please explain below and if there is any other significant information concerning your past medical or dental history, please describe and discuss it with your doctor:
FOR WOMEN ONLY
YESNO
YESNO
YESNO
(Please note any medications prescribed, for your oral surgical care may interfere with the action of birth control pills

Permission is hereby granted to the staff of this office for such procedures and anesthesia as may be necessary for the care of the undersigned patient. Permission is granted to release my medical-surgical records to my primary Dentist or Physician. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist responsible for any errors or omissions that I may have made in the completion of this form.
Patient's Signature*

Clear
Legally responsible person if patient cannot sign or is a minor (under 18)

Clear
Date*

MonthDayYear
Date
Relationship of the above to the patient
Should be Empty: