Health Questionnaire – Initial Visit

Name *

First

Last

Your Cell Number *

May I text you? *

Email *

Date of Birth *

City & State *

Referral

How did you hear about me? Please list website, social media platform, ad, friend’s name or other.

Height: *

Current Weight: *

Current Health Concern – Please provide as much detail as you can. *

Your Health Information – Please select any issues you currently have or have had in the past.

Health History – Please describe any past health issues. *

Allergies (including medications, foods, environmental, seasonal, etc.) *

Medications / Supplements / Vitamins / Herbs – Please list all (including over the counter) along with dosages and how often you take. *

Do you currently have mercury fillings in your teeth (black/gray or silver)? **please check your mouth for these fillings *

Have you had any mercury (black/gray or silver) fillings removed in the past? *

Have you had any tooth extractions (teeth pulled), including wisdom teeth? *

Do you have any root canals? *

Have you had an abcess (an antibiotic required infection in your gums or teeth)? *

Did your Dentist tell you that you have receeding gums? *

IF YOU HAVE BLOOD TEST RESULTS OR OTHER STUDIES THAT YOU WOULD LIKE TO SHARE, PLEASE UPLOAD THOSE IN THE SPACE BELOW.

If you have issues uploading files, respond to the Calendly confirmation email you will receive after scheduling your appointment (next steps) and attach the files there.

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.