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in Santa Fe, New Mexico
Robert L. Wartell, DDS
Kristine B. Ali, DMD
Sandraluz Gonzalez, RDH
Carmen Lucero, CTA

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Health Questionnaire

Completing this form online will allow you to save up to 15 minutes in our office. The form is on a secure page and the information you submit is confidential. Please see our privacy statement. There are three parts to the form - general health questions, list of conditions, and dental health questions. Please answer all parts and all questions.

Name
What should we call you?
Date of Birth
Address
City, State, ZIP
Home Phone Preferred:
Work Phone Preferred:
Cell Phone Preferred:
May we remind you of appointments by text message? Yes No
Employer
Job Title
Email
Whom may we thank for referring you?
Please check the appropriate box
Single         Married         Partner For Insurance      
Divorced     Widowed     Separated
Full name of spouse or partner:
Name and phone for emergency contact:



Please answer all questions. The state of your general health is strongly related to your oral health.
Primary Care Physician
Physician phone
Name of specialist(s)
Date of last medical exam
Have you been hospitalized in last 5 years? Yes No
   If yes, for what
Are you under treatment now? Yes No
   If yes, for what
Taking any prescription medications? Yes No
   If so, list medications, with dose and frequency.
Taking any over the counter medications? Yes No
   If so, list medications, with dose and frequency.
Taking any herbal supplements? Yes No
   If so, list supplements, with dose and frequency.
Do you use tobacco? Yes No
   If so, what and how often
Do you use controlled substances? Yes No
   If so, what


Are you allergic to or had any reactions to:
local anesthetic "Novocaine"
penicillin
sulfa drugs
other antibiotic
barbiturates
narcotics
sedatives
iodine
aspirin
Ibuprofen
any metals
latex rubber
any other
   If so, what?


Please answer ALL questions, even if your answer is "no."
Do you have or have you ever had
high blood pressure? Yes No
heart disease? Yes No
chest pains? Yes No
a heart attack? Yes No
a pacemaker? Yes No
easily winded? Yes No
heart surgery? Yes No
heart stent? Yes No
a stroke? Yes No
swollen ankles? Yes No
angina? Yes No
hay fever? Yes No
environmental allergies? Yes No
fainting? Yes No
seizures? Yes No
frequently tired? Yes No
tuberculosis? Yes No
asthma? Yes No
anemia? Yes No
radiation therapy? Yes No
low blood pressure? Yes No
emphysema? Yes No
glaucoma? Yes No
epilepsy? Yes No
convulsions? Yes No
cancer? Yes No
leukemia? Yes No
arthritis? Yes No
liver disease? Yes No
diabetes? Yes No
thyroid disease? Yes No
joint replacement? Yes No
implant? Yes No
kidney disease? Yes No
hepatitis? Yes No
jaundice? Yes No
respiratory problems? Yes No
AIDS/HIV? Yes No
sexually transmitted disease? Yes No
unexplained weight loss? Yes No
ulcers? Yes No
anything else? Yes No
   If so, what?

Please answer the following questions about your dental health.

Most recent dentist
Dentist location
Dentist phone
date of last dental visit
How often do you brush?
how often do you floss?
Please explain in detail what you would like us to do for you.

Do you have:
bleeding gums? Yes No
teeth sensitive to heat? Yes No
teeth sensitive to cold? Yes No
teeth sensitive to sweets? Yes No
pain in your teeth? Yes No
sores or lumps in your mouth? Yes No
any head or neck injuries? Yes No
clicking in a jaw joint? Yes No
pain in a jaw joint? Yes No
difficulty opening or closing? Yes No
difficulty chewing? Yes No
frequent headaches? Yes No
grinding or clenching your teeth? Yes No
difficulty with extractions? Yes No
difficulty with fillings? Yes No
prolonged bleeding after extractions? Yes No
orthodontic treatment? Yes No
dental implant(s) Yes No
dentures or partial dentures? Yes No
What would
you like to change
about your smile?
Thank you for taking the time to complete this form.



We enjoy answering your questions.
For more information, please call us at 505-474-4644

Center For Dental Medicine • 2019 Galisteo St. • J2 • Santa Fe, NM 87505
(Behind Los Alamos National Bank, St. Michael's & Galisteo) Map

You may contact us by:
phone: 505-474-4644
Email Us
postal: 2019 Galisteo St., J2, Santa Fe, NM 87505

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