Adult Health & Business Questionaire Form - Alberta - Canada Page 2
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1
2Do you suffer frequent colds?………….…………………………………………………..…………....
8.
YES
NO
Do you have difficulty breathing through your nose?………………………………………………..….
9.
YES
NO
Have you ever had abnormal bleeding associated with previous extractions, surgery or trauma?……...
10.
YES
NO
11.
Have you ever (at any age)had an injury to the head, neck, face, teeth or chin?
...
YES
NO
(ie. Stitches, concussions, whiplash)
If Yes, explain ______________________________________________________________
Is there any other information I should know about your health or previous dental treatment?….…..…
12.
YES
NO
If Yes, explain:______________________________________________________________
(Women ) Are you pregnant? ……………………………………………………..………….…………..
13.
YES
NO
Do you have a metal or latex sensitivity?…………………………………………………………………
14.
YES
NO
15.
What is your main reason for seeking orthodontic care?________________________________________________________
Have you previously or do you currently wear an appliance for jaw joint issues? ………………………
YES
16.
NO
) ………………………………..….
YES
17.
Do you see a dentist for regular preventative care? (
NO
cleanings, checkups
Have you ever been told that you require antibiotics prior to dental treatment?…………………….…….
YES
18.
NO
19.
Have you had a recent exposure to any communicable infectious diseases?
..
YES
NO
(measles, chicken pox or Tuberculosis)
20.
In the last 24 hours have you had a new cough, shortness of breath, fever, chills, diarrhea or other flu-
like symptoms? ………………………………………………………………………………………….…
YES
NO
INSURANCE INFORMATION
Policy Holder Name
__________________________________
(2) ______________________________________
Policy Holder Birthdate __________________________________
______________________________________
Insurance Company
__________________________________
______________________________________
Group/Policy
__________________________________
______________________________________
I.D./Cert.No.
__________________________________
______________________________________
ACCOUNTING INFORMATION
Person responsible for payment of account if different from patient:
Name: (Last)_________________________ (first)______________________________Relationship___________________________
Address:_________________________________________________________________Phone # ____________________________
__________________________________________________________________Postal Code _________________________
Occupation: ______________________________ Work # _____________________
AUTHENTIC ORTHODONTICS
#540, 19489 Seton Cr SE Calgary, AB T3M 1T4
PH 403-523-9101 FAX 430-523-9102
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