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Confidential Health Questionnaire
If you have already scheduled a consultation, you may save time at your visit.  Fill out the following form, print it and bring it with you for your consultation.  Be sure to fill out the Registration Form as well.

PA Institute of Oral Surgery

Name

Email Address

 

Dentist

 Dentist's Phone

Medical Doctor

 Doctor's Phone
My major problem or reason for seeking treatment is:
Consultation   Impacted Teeth Extractions  
Dental Implants Fractured Jaw Jaw Surgery 
Oral Lesions Cysts or Tumors Facial Pain
Biopsy Apicoectomy TMJ
Other 
 
Have you ever had a serious illness or major operation? Yes No
If yes, please describe:
 
Have you ever had general anesthesia? Yes No
If yes, please describe:
 
Are you now under the care of a physician? Yes No
If yes, please describe:
 
Are you presently taking any medication or drugs? Yes No
If yes, please describe:
 
Have you ever had an allergic reaction to medication or anesthesia? Yes No
If yes, please describe:
 
Have you ever required a blood transfusion? Yes No
If yes, please describe:
 
Have you ever been in contact with any individual having Hepatitis, Tuberculosis (TB) or AIDS? Yes No
If yes, please describe:
 
Are you addicted to or recovering from any drug or alcohol addition? 
Yes No
If yes, please describe:
 
Do you have any visual or hearing problems, or any other disabilities which we should consider in planning your surgical treatment? Yes No
If yes, please describe:
Are you wearing contact lenses? Yes No
Do you have or have you had any of the following:
Yes No   Rheumatic Fever Yes No   Rheumatic heart disease 
Yes No   Congenital heart disease Yes No   Heart murmur
Yes No   Heart trouble Yes No   Pacemaker
Yes No   Heart surgery Yes No   Bypass surgery
Yes No   Prosthetic heart valve Yes No   Heart attack
Yes No   Angina Yes No   Stroke
Yes No   Sleep apnea Yes No   High blood pressure
Yes No   Low blood pressure Yes No   Diabetes
Yes No   Hypoglycemia Yes No   Prosthetic hip
Yes No   Prosthetic joint Yes No   Hepatitis
Yes No   Jaundice Yes No   Liver disease
Yes No   H.I.V Yes No   Immune System Deficiency
Yes No   Veneral disease (VD) Yes No   Syphilis
Yes No   Gonorrhea Yes No   Herpes infection
Yes No   Fever blister Yes No   Cold sore
Yes No   Hemophilia Yes No   Anemia
Yes No   Bleeding disorder Yes No   Kidney disease
Yes No   Dialysis Yes No   Kidney transplant
Yes No   Seizure disorder Yes No   Epilepsy
Yes No   Convulsion Yes No   Asthma
Yes No   Hay fever Yes No   Allergy
Yes No   Tuberculosis (TB) Yes No   Persistent cough
Yes No   Cancer Yes No   Radiation treatment
Yes No   Chemotherapy Yes No   Stomach ulcer
Yes No   Arthritis Yes No   Thyroid disorders
For women only:
Yes No  Are you pregnant? 
Yes No  Are you taking birth control pills or hormones? 

If you checked "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 with your doctor: 

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. (If you are emailing this form, signature must be obtained the day of your consultation or you can print this form out and bring it with you.)
 
Patient's Signature Date
Doctor's Signature Date
 
Legally responsible person if patient cannot sign 
or is a minor (under 18 years of age)
Relationship of the above to the patient
 

Forms needed:
Registration Form

drmadani@paoralsurgery.com PA Institute of Oral Surgery (610) 667-6161