General Medical Questionnaire
 


Name:
D.O.B.:

    
 
Questions:		    
1. Is this your first visit to this practice?   Yes/No
2. What is the state of your health?   Good / Average / Bad
3. Have you been seriously ill, been admitted to hospital or undergone an operation since your last dental visit?
   Yes/No
4. If yes, for what medical condition?   ...........................................................
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5. Have you ever experienced complications as a result of a dental treatment?
   Yes/No
6. If yes, what complications?   ...........................................................
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7. Are you using any medications?    
8. If yes, which medicines?   ...........................................................
...........................................................
...........................................................
9. Do you have high or low blood pressure?   High / Low / Unknown
10. Do you have a medical condition relating to:    
  - heart and/or blood vessels?   Yes/No
  - liver and/or gallbladder?   Yes/No
  - kidneys and/or bladder?   Yes/No
  - lungs?   Yes/No
  - stomach and/or intestines?   Yes/No
  - epilepsy?   Yes/No
  - hyperventilation?   Yes/No
  - diabetes?   Yes/No
  - infectious diseases?   Yes/No
  - hemorrhaging?   Yes/No
11. Do you use blood thinners?   Yes/No
12. Are there any other matters relating to your health that you feel may be relevant to your treatment and that your dentist should know about?
  Yes/No
13. If yes, which matters?   ...........................................................
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Signature: 		  Date: