Periodontal disease may be caused by a combination of several factors and the following questions are designed to help us identify them. The success of therapy is dependent upon this. Therefore, although some of the following questions may seem unrelated to your periodontal condition, they are all associated with proper management of your oral health.

All information is kept strictly confidential.

Who is your family physician?[text family_physician id:family_physician]

Are you taking blood thinners?[radio blood_thinners use_label_element default:0 "Yes" "No" "Don't Know"]

Are you taking or have you taken any drugs within the past year?....(example: aspirin, tranquilisers, steroids, etc.)*[radio medication use_label_element default:0 "Yes" "No" "Don't Know"]If so, please list[text medication_details id:medication_details]

Have you had heart surgery or joint replacement?[radio heart_surgery use_label_element default:0 "Yes" "No" "Don't Know"]

Do you have or have you ever had any of the following conditions:[checkbox past_conditions use_label_element class:cpm-form-three-column-list "Asthma" "Hives or Skin Rash" "Hepatitis (liver disease)" "Rheumatic Fever" "Tumor or Growth" "Thyroid or Parathyroid Disorder" "Heart Murmur" "Frequent Headaches" "Kidney Problems" "Heat Problems - Angina" "Sinusitis" "Arthritis or Rheumatism" "Heart Attach" "Radiation Therapy" "Ulcers" "High Blood Pressure" "Lupus" "Tuberculosis" "Heart Surgery" "Tendency to Faint" "Emphysema" "Stroke" "Epilepsy" "Cancer" "Herpes" "Scarlet Fever" "Diabetes" "Glaucoma" "Anaemia" "Seizures or Convulsions" "Prostate Disorders" "Abnormal Blood Count" "Jaundice" "H.I.V." "Hay Fever"]

For each of the questions below, check the box if your answer is YES.[checkbox medical_questions_1 "Has your general health changed in the past year?" "Has your weight changed in the past year?" "Have you ever had any serious illness or major operations?" "Have you had abnormal bleeding associated with previous tooth extraction, surgery, or trauma?" "Do you heal slowly?" "Have you ever had any allergies? (food, dust, drugs, fur, latex, etc.)?"]

Are you allergic or have you had an adverse reaction to any of the following? (Check all that apply)[checkbox allergies_reactions "Dental anaesthetics (novocaine, etc.)" "Aspirin" "Penicilin or other antibiotics" "Codeine" "Barbituates (sleeping pills)" "Other drugs"]

For each of the questions below, check the box if your answer is YES.[checkbox medical_questions_2 "Do you consider yourself a nervous person?" "Have you ever been warned against taking any drug or medicine?" "Have you ever had an asthmatic attach?" "Are you ever short of breath or have chest pains after mild exertion?" "Do your ankles swell?" "Are you thirsty much of the time?" "Do you have a persistent cough or do you cough up blood?" "Do you consider yourself a nervous person?" "Have you ever had surgery or treatment for a tumour or growth of your head, mouth, or lips?"]

Has anyone in your family ever had diabetes?[radio family_diabetes use_label_element default:0 "Yes" "No" "Don't Know"]If so, who?[text diabetes_details id:diabetes_details]

Do you smoke or have you ever smoked or used other tobacco products?[radio smoker use_label_element default:0 "Yes" "No" "Don't Know"]If yes, how long?[text smoker_details id:smoker_details]Date quit:[text smoker_quit id:smoker_quit]

What is your reason for coming to this office?[text reason_for_visit id:reason_for_visit]

For each of the questions below, check the box if your answer is YES.[checkbox dental_questions_1 use_label_element "Are you experiencing pain from your mouth at this time?" "Have you been experiencing pain from your mouth lately?" "Have you had any swelling or bleeding of the gums?" "Have your gums been receding?" "Have you noticed bad mouth odors or tastes?" "Have your front teeth separated, creating spaces between them lately?" "Have you noticed any loose teeth?" "Have you ever been told that you have periodontal disease or pyorrhea?" "Do you feel that your teeth come together evenly?" "Do you clench or grind your teeth during the day or night?" "Are you conscious of sore teeth, loose teeth or high fillings?" "Would you be tremendously disturbed if you had to lose your teeth and wear false teeth?" "Would you be willing to spend several minutes per day cleaning your teeth?" "Are you satisfied with the appearance of your teeth?" "Have you ever had orthodontic treatment (braces)?" "Do you breathe primarily through your mouth?"]

How often do you brush your teeth?[radio brushing_habits use_label_element default:0 "Once per day" "Twice per day" "Three or more times per day"]

Have you, in the past, ever had periodontal (gum) treatments?[radio periodontal_treatments use_label_element default:0 "Yes" "No" "Don't Know"]If so, by whom?[text periodontal_treatment_details id:periodontal_treatment_details]When did you last have your teeth cleaned?[text periodontal_treatment_when id:periodontal_treatment_when]

What type of brush do you use?[radio type_of_brush use_label_element default:0 "Hard" "Medium" "Soft" "Extra Soft"]

What home care aids are you currently using?[checkbox dental_aids use_label_element "Dental Floss" "Stimudents" "Water Pik" "Rubber Tip" "Proxy Brush" "Mouthwash" "Electric Toothbrush"]

Are you pregnant?[radio pregnant use_label_element default:0 "Yes" "No" "Don't Know"]If yes, when is your expected due date?[text pregnant_date id:pregnant_date]

Have you reached menopause?[radio menopause use_label_element default:0 "Yes" "No" "Don't Know"]

NOTE: certain medications (e.g. antibiotics) may inhibit the effectiveness of oral contraceptives.

[acceptance consent]I hereby give consent to have a periodontal (dental) examination and or relief of pain treatment. This treatment may include use of various medications such as: local anaesthetics (freezing), antibiotics, analgesics (pain killers) and others as required.