New Health Informational Form

  • ALL ALASKA ORAL & CRANIOFACIAL SURGERY
    CONFIDENTIAL HEALTH QUESTIONNAIRE

    • My problem or reason for seeking treatment is:

    • 1. Are you in general good health?

    • If not, please describe

    • 2. Do you have any mobility issues?

    • If yes, do you use a wheelchair?

    • 3.Are you currently under the care of a physician?

    • If yes, what is the condition being treated:

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

    • If yes, please describe:

    • 5.Have you ever had any problems while under Sedation and/or General Anesthesia?

    • If yes, please describe your experience:

    • 6.Do you have a cold, sore throat, or upper respiratory illness now?

    • If yes, what is the duration:

    • 7.Are you presently taking any medications or drugs?

    • If yes, list them here:

    • Also check any of the following if you are taking them:

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

    • If yes, please describe:

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

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

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

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

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

    • If yes, please describe:

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

    • If yes, please describe:

    • 14.If you need special accommodations, please describe how we can make your appointments and surgery go smoothly.

    • 15. Do you have a history of any of the following? (Please check yes or no – do not leave any blank.)

    • 16. Have you ever taken/used or currently take/use any of the following?

    • 17. Do you have any other medical problems not listed above?Please list.

    • For women only

      a. Are you pregnant or trying to become pregnant?

    • b. 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.)
    • 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

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