Online Health Questionnaire - Hockley Family Dentistry

All doctors can be reached at: (902) 825-3343

reception@hockleyfamilydentistry.ca

Covid-19 Return to Practice Details

All Doctors: (902) 825-3343

reception@hockleyfamilydentistry.ca

Covid-19 Return to Practice Details

New Patients Welcome

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Online Health Questionnaire

Health questionnaire to be filled out by patients prior to their first appointment at Hockley Family Dentistry

Step 1 of 5

20%

Patient Personal Info

All patient info will be held confidential by management/doctors at Hockley Family Dentistry and retained for informational purposes

Full Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Month

Day

Year

Parents/Guardian or Spouse

Mailing Address(Required)

Street Address City Province Postal Code

Civic Address(Required)

Same as mailing address

Street Address City Province Postal Code

Home Phone

Cell Phone(Required)

Work Phone

Patient Insurance, Health Plan & Doctor Info

All patient info will be held confidential by management/doctors at Hockley Family Dentistry and retained for informational purposes

Dental Insurance Company(Required)

Employer/Business Name(Required)

Group/Policy #

Certificate/ID #

Div. #

NS Health Card #(Required)

Health Card Expiry Date(Required)

Month

Day

Year

Medical Physician Name

Prefix First Last

Physician's Phone

Patient Medical Questions

All patient info will be held confidential by management/doctors at Hockley Family Dentistry and retained for informational purposes

Are you being treated for any medical condition presently or have you been treated within the past 6 months?(Required)

Yes

No

If so, what is the condition being treated?(Required)

Are you taking any medication at the present time?(Required)

Yes

No

If so, what medication are you taking?(Required)

Have you ever been seriously ill?(Required)

Yes

No

If so, what was the illness?(Required)

Any allergies to food or drugs, etc.?(Required)

Yes

No

If so, what allergies do you have?(Required)

Have you ever had radiation therapy?(Required)

Yes

No

Date of Radiation Therapy(Required)

Month

Day

Year

Have you ever had a joint replacement?(Required)

Yes

No

Date of Joint Replacement Procedure(Required)

Month

Day

Year

Are you pregnant at the present time?(Required)

Yes

No

Due Date(Required)

Month

Day

Year

Patient Medical History

Do you currently have or have you ever had any of the following?

Diabetes(Required)

Yes

No

Jaundice(Required)

Yes

No

Severe Sore Mouth(Required)

Yes

No

Asthma(Required)

Yes

No

Hay Fever(Required)

Yes

No

Hives(Required)

Yes

No

Hepatitis(Required)

Yes

No

Sinus Trouble(Required)

Yes

No

Liver Trouble(Required)

Yes

No

Reaction to Local Anesthetic(Required)

Yes

No

Arthritis(Required)

Yes

No

Prolonged Bleeding after Cut(Required)

Yes

No

Psychological Disorders(Required)

Yes

No

HIV Positive(Required)

Yes

No

Pacemaker(Required)

Yes

No

Thyroid Condition(Required)

Yes

No

Tuberculosis(Required)

Yes

No

Heart Attack(Required)

Yes

No

Stroke(Required)

Yes

No

Heart Murmur(Required)

Yes

No

High Blood Pressure(Required)

Yes

No

Chest Pain(Required)

Yes

No

Shortness of Breath(Required)

Yes

No

Rheumatic Fever(Required)

Yes

No

Epilepsy(Required)

Yes

No

Kidney Disorders(Required)

Yes

No

Stomach Ulcers(Required)

Yes

No

Osteoporosis(Required)

Yes

No

Patient/Legal Guardian Signature

By inputting your full name and date you are digitally signing the form. This declares that you confirm that all information submitted is accurate and released to Hockley Family Dentistry. Provide legal guardian name if patient is under 19 or unable to provide consent.

Full Name(Required)

First Last

Date of Signature(Required)

Month

Day

Year

Office Hours & Address

MON – FRI
8:30am – 4:30pm

SAT - SUN
CLOSED

The office hours are subject to change.

Address
7 Maple Ave
P.O.Box 878
Middleton, NS
B0S 1P0

Contact Us

All Doctors Can Be Reached At

(902) 825-3343

Office Fax

(902) 825-6437

Office Email

reception@hockleyfamilydentistry.ca

Write to Us

Don't be shy. Let us know if you have any questions!

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