Address: 4200 Lake Otis Pkwy Suite 202, Anchorage, AK, 99508, US
Telephone: (907) 764-4760

ALL ALASKA ORAL & CRANIOFACIAL SURGERY
CONFIDENTIAL HEALTH QUESTIONNAIRE
PATIENT NAME
DATE *
My problem or reason for seeking treatment is:
General Dental Care

Fractured Jaw

Snoring & Sleep Apnea

Impacted Teeth
Practice Name

Oral Lesions

Apicoectomy

Facial Pain
Extractions

Cysts or Tumors

Orthodontics

Jaw Surgery
Other
1. Have you ever had a serious illness or major operation?
Yes No
If yes, please describe:
2.Have you ever had General Anesthesia?
Yes No
If yes, please describe your experience:
3.Are you now under the care of a physician?
Yes No
If yes, what is the condition being treated:
4.Do you have a persistent cough?
Yes No
If yes, what is the duration:
5.Are you presently taking any medications or drugs?
Yes No
If yes, list them here:
Also check any of the following if you are taking them:
Aspirin

Herbal Supplement

Disronel

Zometa

Loron

Aclasta
Vitamin E

Fosamax

Aredia

Boniva

Skelid

Reclast
Coumadin (blood thinner)

Bisphosphonates

Actonel

Bonefos

Nerixia

Atelvia
6.Have you ever had an allergic reaction to medication or anesthesia?
Yes No
If yes, please describe:
7.Have you ever required a blood transfusion or have bleeding disorders?
Yes No
8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?
Yes No
8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?
Yes No
9. Are you addicted to or recovering from any drug or alcohol addiction?
Yes No
10. Are you wearing contact lenses? If yes, remove your contacts prior to surgery.
Yes No
11.Do you have any visual or hearing problems? Or any other disabilities which we should consider in planning your oral surgical treatment?
Yes No
If yes, please describe:
Primary Care Physician
Phone
Street
City
State
Zip
12. Do you have a history of any of the following? (Please check yes or no – do not leave any blank.)
High Blood Pressure / Hypertension

Yes No

Heart Murmur

Yes No

Rheumatic Fever / Rheumatic Heart Disease

Yes No

Mitral Valve Prolapse

Yes No

Angina Pectoris / Chest Pain Upon Exertion

Yes No

Heart or Bypass Surgery

Yes No

Heart Disease

Yes No

Prosthetic (Artificial) Heart Valve

Yes No

Irregular / Rapid Heart Beat

Yes No

Pacemaker / Implanted Defibrillator

Yes No

Pacemaker / Implanted Defibrillator

Yes No

Heart Attack

Yes No

Stroke / TIA

Yes No

Sleep Apnea

Yes No

Emphysema / Respiratory Problems

Yes No

Asthma or Hay Fever

Yes No

Diabetes

Yes No

Hypoglycemia

Yes No

Thyroid Disease

Yes No

Persistent Swollen Neck Glands

Yes No

Psychiatric Treatment

Yes No

Osteoporosis

Yes No

Bone Disease

Yes No

Osteogenesis Imperfecta

Yes No
Anemia

Yes No

Bleeding Disorder

Yes No

Kidney Disease

Yes No

Dialysis

Yes No

Organ Transplant

Yes No

Cancer

Yes No

Radiation Therapy

Yes No

Chemotherapy

Yes No

Epilepsy / Seizure / Convulsion

Yes No

Stomach Ulcer / Hyper-Acidity

Yes No

Colitis / Intestinal Problem

Yes No

Arthritis and/or Painful Swollen Joints

Yes No

Prosthetic (Artificial) Joints

Yes No

Jaw Join Pain (TMJ) or Clicking/Popping

Yes No

Sexually Transmitted Disease (STD)

Yes No

AIDS / HIV

Yes No

Tuberculosis (TB)

Yes No

Frequent or Recurring Mouth Sores

Yes No

Frequent or Recurring Mouth Sores

Yes No

Hepatitis / Jaundice / Liver Disease

Yes No

Allergy to Latex

Yes No

Bone Cancer

Yes No

Paget’s Disease

Yes No

Myeloma / Multiple Myeloma

Yes No
13. Have you ever taken/used or currently take/use any of the following?

Appetite Suppressant (such as Fen-Phen) Tobacco Alcohol Recreational Drugs
14. Do you have any other medical problems not listed above?
a. Are you pregnant or trying to become pregnant?
Yes No
Are you taking birth control pills or Hormones?

(Please note any medications prescribed for your oral surgical care may interfere with the action of birth control pills.)
Yes No
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. Permission is also granted to take x-rays, images, or photographs that could be used for diagnostic or educational purposes. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set fourth above have been answered to my satisfaction. I will not hold my dentist responsible for any errors or omissions that I may have made in the completion of this form.
Signature of patient or legal guardian X
Relationship to patient
Doctor's Comments
Doctor’s Signature
Date

Contact Info

Contact Us

Health Informational Form

ALL ALASKA ORAL & CRANIOFACIAL SURGERY
CONFIDENTIAL HEALTH QUESTIONNAIRE

1. Have you ever had a serious illness or major operation?

2.Have you ever had General Anesthesia?

3.Are you now under the care of a physician?

4.Do you have a persistent cough?

5.Are you presently taking any medications or drugs?

6.Have you ever had an allergic reaction to medication or anesthesia?

7.Have you ever required a blood transfusion or have bleeding disorders?

8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?

8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?

9. Are you addicted to or recovering from any drug or alcohol addiction?

10. Are you wearing contact lenses? If yes, remove your contacts prior to surgery.

11.Do you have any visual or hearing problems? Or any other disabilities which we should consider in planning your oral surgical treatment?

LOCATION

All Alaska Oral & Craniofacial Surgery

SUBSCRIBE

Contact Info

Contact Us

Health Informational Form

ALL ALASKA ORAL & CRANIOFACIAL SURGERY CONFIDENTIAL HEALTH QUESTIONNAIRE

1. Have you ever had a serious illness or major operation?

2.Have you ever had General Anesthesia?

3.Are you now under the care of a physician?

4.Do you have a persistent cough?

5.Are you presently taking any medications or drugs?

6.Have you ever had an allergic reaction to medication or anesthesia?

7.Have you ever required a blood transfusion or have bleeding disorders?

8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?

8.Have you ever been in contact with any individual having Hepatitis, Tuberculosis (T.B.), or AIDS?

9. Are you addicted to or recovering from any drug or alcohol addiction?

10. Are you wearing contact lenses? If yes, remove your contacts prior to surgery.

11.Do you have any visual or hearing problems? Or any other disabilities which we should consider in planning your oral surgical treatment?

LOCATION

All Alaska Oral & Craniofacial Surgery

SUBSCRIBE

ALL ALASKA ORAL & CRANIOFACIAL SURGERY
CONFIDENTIAL HEALTH QUESTIONNAIRE