Consultation questionnaire - Rockland Othodontiste

Patient

Name*

First Last

M
F

DOB (YYYY/MM/DD)*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Work / Cell Phone

Email*

Marital status

Single
Partnered
Married
Seperated/Divorced

Patient's dentist

Date of last dental appointment

Patient's physician

Date of last medical appointment

Patient referred by

Responsible Party

Name*

First Last

Relationship to patient*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Work / Cell Phone

Email*

Marital status

Single
Partnered
Married
Seperated/Divorced

Relationship to patient*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Work / Cell Phone

Email*

Marital status

Single
Partnered
Married
Seperated/Divorced

Medical History

Are you in good general health?

Yes
No

If not, please specify:

Have you been hospitalized?

Yes
No

If so, please specify:

Taking any prescription or non-prescription drugs?

Yes
No

If so, please specify:

History of allergies?

Yes
No

If so, please specify:

Rheumatic fever, endocarditis

Yes
No

Any prosthetic joints

Yes
No

Blood disorder, anemia

Yes
No

Bleeding or healing disorder

Yes
No

Asthma, hay fever

Yes
No

High or low blood pressure

Yes
No

Dizziness or loss of consciousness

Yes
No

Hepatitis, Jaundice or liver disease

Yes
No

Arthritis

Yes
No

Kidney disease

Yes
No

Frequent headaches, ear aches

Yes
No

Tuberculosis, pulmonary disease

Yes
No

Digestive problem, stomach ulcer

Yes
No

Vision problem, glaucoma

Yes
No

Epilepsy

Yes
No

Sinusitis

Yes
No

Sexually transmitted disease (STD), HIV positive (AIDS)

Yes
No

Diabetes

Yes
No

Thyroid disease

Yes
No

Radiation, chemotherapy treatment

Yes
No

Skin disease

Yes
No

Neurological problem

Yes
No

For women only - Are you pregnant?

Yes
No

Past head or face injury

Yes
No

Past tooth injury (broken or chipped teeth, blow to teeth)

Yes
No

Past tooth extraction(s)/removal(s)

Yes
No

Past/current thumbsucking habit

Yes
No

Have the tonsils and/or adenoids been removed?

Yes
No

Speech problem

Yes
No

Mouth breathing

Yes
No

Clenching/Grinding

Yes
No

Previous orthodontic treatment(s)/consultation(s)

Yes
No

CAPTCHA

Patient

Responsible Party

Medical History

Office Hours

Contact