• BALA INSTITUTE OF ORAL SURGERY
    15 PRESIDENTIAL BOULEVARD, SUITE 301     ⬧ BALA CYNWYD, PA 19004 (610) 667-6161 ⬧ WWW.BALASURGERY.COM

  • CONFIDENTIAL HEALTH QUESTIONNAIRE

  • Date of Birth*
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  • My reason for seeking treatment is:*

  • 1. Have you ever had a serious illness or major operation?*
  • 2. Have you ever had general anesthesia?*
  • 3. Are you now under the care of a physician? If yes, what is the condition being treated?*
  • 4. Are you currently taking any blood thinners? (i.e., aspirin, Coumadin, Xarelto, Plavix)*
  • 5. Are you presently taking or have you ever taken bisphosphonates? (i.e., Fosomax, Reclast)*
  • 6. Are you presently taking any other medication(s)?*
  • 7. Are you allergic to or have you had an allergic reaction to (if no, specify NONE in other below):*
  • If yes, please specify.*

  • 8. Have you ever required a blood transfusion?*
  • 9. Do you wear contact lenses?*
  • 10. Do you have any visual or hearing problems, or any other disabilities, which we should consider in planning your oral surgical treatment?*
  • 11. Have you ever been in contact with any individual having any of the following listed below?*
  • If yes, please specify.
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  • 12. Do you currently have or have you ever had any of the following conditions? 

  • Angina pectoris/Chest pain*
  • Heart attack (Myocardial Infarction (MI)*
  • Stroke/TIA*
  • Congestive heart failure*
  • Rapid/Irregular heart beat*
  • Rheumatic heart disease*
  • Heart murmur*
  • Mitral valve prolapse*
  • Heart or bypass surgery*
  • Stent placement/Angioplasty*
  • Prosthetic (artificial) heart valve*
  • Pacemaker/Implanted defibrillator*
  • Hyperlipidemia*
  • High blood pressure*
  • Low blood pressure*
  • Blood clot/DVT, PE*
  • Bleeding disorders/Hemophilia*
  • Anemia*
  • Sickle cell disease/trait*
  • Asthma*
  • Emphysema/ COPD*
  • Sleep apnea*
  • Hepatitis (A, B, C)*
  • Tuberculosis (TB)*
  • AIDS / HIV*
  • Sexually transmitted disease*
  • Diabetes (type I or type II): If yes, specify in question #13*
  • Hypoglycemia*
  • Thyroid disease*
  • Epilepsy / Seizure / Convulsion*
  • Alzheimer's disease/Dementia*
  • Migraines*
  • Acid reflux/GERD*
  • Stomach ulcer*
  • Arthritis (Rheumatoid/Osteoarthritis)*
  • Osteoporosis/Osteopenia*
  • Joint replacement*
  • Jaw joint pain (TMJ) or clicking/popping*
  • Cancer: If yes, specify type in question #13*
  • Chemotherapy/Radiation therapy*
  • Bone marrow transplant*
  • Anxiety*
  • Depression*
  • ADD/ADHD*
  • Schizophrenia*
  • PTSD*
  • Kidney disease*
  • Dialysis*
  • Liver disease*
  • Organ transplant*
  • 13. Do you currently take/use any of the following?

  • FOR WOMEN ONLY

  • a. Are you pregnant or trying to become pregnant?
  • b. Are you currently breast-feeding
  • c. Are you taking birth control pills or Hormones?

  • (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.

  • Date*
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