First Name
E-Mail
DENTAL MEDICAL HISTORY QUESTIONNAIRE
Address
Last Name
City
State
Zip
Phone # (if none, put none)
Date of Birth
Procedures Requested
Gender
Have you ever been told or required to be pre-medicated before a surgery or a dental procedure?
What is your primary goal?
(Relieve pain, perfect smile, etc)
Please answer yes or no to each condition/question below:
Hypertension/High Blood Pressure
Diabetes
Heart Condition
Sjourgens Disease
Swelling in the mouth
Bleeding when you brush
Are you taking blood thinners?
Do you have problems with wounds healing?
Do you have any allergies, including to anesthesia?
Please list your current medications
Are there any other conditions not listed above?
Have you ever taken a biophosphonate medication?
Height
Weight
Do you have any medical condition that you have been told would disqualify you for any type of dental procedure or surgery?
Do you have any other medical condition that you are aware of that is not listed above?
How did you hear about us?
Do you have special needs that need accommodation? (dietary, sensory, handicap, etc)
Do you have current XRAYS or a dental treatment plan?
Please list all previous surgeries, hospitalizations and allergies
Upload your XRAYS or Treatment plans
Agreement: By clicking the Submit button, I certify that I have read, understand and agree to the Privacy Policy and Terms of Use posted on this website. I have the right to submit the above information and agree that it is accurate to the best of my knowledge and that skyMedicus and its affiliates are authorized to use it in any way on my behalf to secure health services. I further understand that electronic copy of this Authorization is as equally valid as any original signature or document.
Please tell us more about your dental needs using the below mouth diagram and the corresponding numbered tooth chart below the mouth diagram.
Tooth #
from chart
Pain
1 = mild
10 = severe
Sensitivity
1 = mild
10 = severe
If missing
how long
(months)?
Previous dental
Briefly explain needs
1
2
3
4
5
6
7
8
9
14
15
16
17
18
19
20
21
22
23
24
28
25
31
30
29
26
27
13
12
11
10
1
32
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