(819) 317-1777(819) 317-1776

Medical questionnaire

If you have ever been a patient at our clinic, Please inform us BEFORE completing this form.

General Patient Information

MF
YesNo
The drop-down menu suggests insurance companies accepted by our system for e-quotes. If your insurance company is not on this list, we will not be able to electronically send the quote. Please bring your insurance information to your appointment so we may send the e-quote to your insurance company. It will be given to you at the clinic and it is your responsibility to send it.
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Medical history

Do you have or have you ever had:

(Check the boxes that apply to your past or present situation.)

Other medical questions or habits

Do you have any implants in your body (heart valve, knee, hip)?
YesNo
If so, which implant and since when?
Do you suffer or have you suffered from sleep apnea symptoms?
YesNo
If so, have you ever done a polysomnography (PSG) (sleep study)?
YesNo
Do you drink alcohol?
YesNo If so, how many beverages per week?
Do you smoke?
YesNo If so, how much per day?
Do you use marijuana products?
YesNo If so, how often?
Do you use any street drugs?
YesNo
If so, which ones?
Are you pregnant?
YesNo If so, which trimester?
Are you nursing?
YesNo
Any other health problems you want to mention?

Allergies and medication

Do you have any allergies to any medication?
YesNo
If so, which ones?
Have you (or a familly member) ever had complications due to general anesthesia?
YesNo
If so, explain:
Do you have any known food allergies?
YesNo
If so, which ones?
Are you on (or have you ever been on) bisphosphonates (i.e. Fosamax, Actonel, Didrocal) or other medication such as Xgeva (Prolia)?
YesNo
Are you taking blood thinners?
YesNo
If so, which ones?
Are you taking any herbal medicines?
YesNo
If so, which ones?
Please list all medications that you are taking:
If necessary, include a list:

A 48-hour notice is required when you want to cancel or change an appointment. In the case of Non-compliance of this policy, a $105 fee will be charged to your account.

I agree that pictures taken during my appointments can be used for teaching or publishing purposes.
I agree to receive email concerning my care.