Please enter your sign-up information
System information
Assigned to *
ADULT HEALTH QUESTIONNAIRE
The data on this confidential questionnaire is essential to render the best professional care. We appreciate your co-operation in filling out carefully, so that we will have accurate records.
Personal information
Patient name *
Gender *
Date of birth *
Employer
Who referred you
Contact information
Street address *
Apartment No.
Buzzer No.
City *
Postal/Zip code *
State/Province *
Home phone
 
Business phone
 
Cell phone
 
Email address
Personal information
Marital status *
Driver's Licence #:
Social Insurance Number:
Your husband's/wife's given name:
His/Her occupation:
Business phone:
His/Her employer:
Address:
Name of family member responsible for payment of your account:
HEALTH INFORMATION
Current State of Health
1. When did you have your last medical examination? *
Are you now taking any medications? *
2. Specially - DO YOU HAVE, or HAVE YOU EVER HAD
Any Serious Illness? *
Any Serious Operations? *
Heart, or Blood Pressure Problems? *
Blood Disorders or Bleeding Tendencies? *
Rheumatic Fever? *
Lung, or Breathing Problems? *
liver, or Kidney Problems? *
Stomach, or Intestinal Problems? *
Fainting or Dizzy Spells? *
Diabetes? *
Epilepsy? *
Allergies to Food; Skin; Rash; Asthma; Hayfever; Other? *
Have you ever tested positive for:
Hepatitis? *
A.I.D.S. (HIV) ? *
DENTAL INFORMATION
Tuberculoisis? *
Have you ever had implant surgery in one or both of your jaw joints? *
a) If yes, who performed the surgery and when it was done?
b) Are you being followed-up by a dental specialist? *
Unfavourable Drug Reactions, or Allergies to:
Local Anaesthetics ("FREEZING")? *
General Anaesthetics? *
Penicillin? *
Erythromycin? *
Other Antibiotics? *
Aspirin? *
Codeine? *
Other Tranquilizers, Sedatives and Pain Killers? *
Have you had ANY warnings against taking ANY medications? *
Do you smoke? *
Do you use alcohol? *
Do you drink tea or coffee? *
is there ANYTHING ELSE concerning your health that I should know? *
If YES, explain:
For Women: Are You Pregnant?
Expected in:
ADMINISTRATIVE INFORMATION
OFFICE POLICY
Your appointment time will be reserved especially for you. If you are unable to keep appointment we will require 24 hours notice, otherwise it will be necessary to charge for time lost.
Office policy is that services are paid for at each visit as they are performed. However in certain circumstances arrangements for payment may be made by consulting business assistant.
Please indicate one of the following with a check mark:
I wish to pay each visit as the services are performed.
I wish to know the total fee for all work to be done, as well as the number of appointments necessary, so that I can pay equal portions at each appointment.
I wish to discuss special arrangements for payment.
Date *
Signature (to be signed in the office)