MEDICAL-DENTAL QUESTIONNAIRE

A patient’s dental file is protected by law and professional secrecy and kept at the dental office, where only the dentist and his/her staff have access to it. Patients are also entitled to access their file and make corrections.

PERSONAL & CONTACT INFORMATION

Gender
Preferred Language
How did you hear about us?

DENTAL INFORMATION

Are you anxious about dental treatments?
Do you currently have a Dentist?
Frequency Covered

Do you Currently Experience, Check all that Apply

Digital Smile Design (DSD) Evaluation, Check all that Apply

Do you Ever

Do you have

ARE YOU INTERESTED IN A COMPLIMENTARY DIGITAL SMILE EVALUATION?

For your Dental Comfort, Check all that Apply

Have you had or Have Knowledge of, Check all that Apply

Any lumps or swelling in your mouth?
Any complications when given local anesthetic?

MEDICAL HISTORY

Are you presently under a doctor’s care?
Have you had surgery or been hospitalized?
Are you receiving Chemotherapy or Radiotherapy
Are you taking medication/blood thinners? (List All)
Do you take Bisphosphonates for Osteoporosis?
Do you require pre-medication?
Are you pregnant or breastfeeding?
Are you taking birth control or hormones?

Allergies to medications, foods and others (check all that apply)

Existing & Past Medical, Health & Infectious Conditions, Check All that Apply

Other Relevant Medical Information, Check All that Apply

Do you snore?
Do you smoke?
Do you have sleep apnea?
Do you take drugs?

INSURANCE INFORMATION

PATIENT CONSENT & IDENTIFICATION - and - DENTIST’S ACKNOWLEDGMENT

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Bella Dentaire