Health Questionnaire | Dr. Sandeep Dhesi | Oral and Maxillofacial Surgery

dhesibooking@gmail.com
(403) 242-2600

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Confidential Health Questionnaire

Patient Name*

Please include your name.

Email Address*

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Phone Number*

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Dental History

Do you currently have or have you ever had a TMJ problem?*

YesNo

Please select

Have you had any problems with local anesthetic (freezing)?*

YesNo

Please select

Please Specify*

Please complete this field

Medical History

Allergies to medications / other substances:

Please include details

List all medications:

Please include details

Have you ever had a general anesthetic or previous surgery?*

YesNo

Please select

Please Specify*

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Have you or a family member ever had a problem with anesthetic e.g. nausea, vomiting or slow recovery afterwards?*

YesNo

Please select

Please Specify*

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Height*

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Weight*

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Are you pregnant or nursing?*

YesNo

Please select

If pregnant, how many months?

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Do you smoke?*

YesNo

Please select

History of illicit drugs?*

YesNo

Please select

Have you had an injury or surgery to the face of jaws?*

YesNo

Please select

Please Specify*

Please complete this field

Have you had Radiation or Cancer of the head or neck?*

YesNo

Please select

Please Specify*

Please complete this field

Check all that apply:

Epilepsy / SeizureDiabetesStrokeThyroid DiseaseCongenital Heart DefectLiver Disease / Hepatitis / JaundiceHeart Attack / Chest PainHIV / AIDSAnemiaHeart MurmurBlood thinners (e.g. Coumadin or Plavix)High Blood PressurePacemaker / ICDEasy Bruising or Prolonged BleedingRheumatic FeverHemophilia / Sickle Cell DiseaseOther Hematologic DiseaseAsthmaEmphysema / COPDTuberculosis (TB)Other Lung DiseaseArthritisArtificial Joints or Heart ValvesKidney Disease / DialysisAddictions / AlcoholismGastrointestinal problemsCancerPeptic Ulcer DiseasePsychological / Psychiatric Diagnosis Invalid Input

With regards to Diabetes, please select:*

InsulinNo Insulin

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With regards to Congenital Heart Defect, please specify*

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With regards to Liver Disease / Hepatitis / Jaundice, please specify*

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With regards to Heart Attack / Chest Pain, please specify*

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With regards to Other Hematologic Disease, please specify*

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With regards to Other Lung Disease, please specify*

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With regards to Artificial Joints or Heart Valves, please specify*

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With regards to Kidney Disease / Dialysis, please specify*

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With regards to Addictions / Alcoholism, please specify*

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With regards to Gastrointestinal problems, please specify*

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With regards to Cancer, please specify*

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With regards to Psychological / Psychiatric Diagnosis, please specify*

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Do you have any other medical conditions not listed?*

YesNo

Please select

Please Specify*

Please complete this field

I believe that the above medical history is, to the best of my knowledge, accurate and complete.

Please confirm that the submitted information is accurate and complete.

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4555 Richardson Rd. SW.
Calgary, Alberta T3E 7E6
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Phone: (403) 242-2600
Fax: (403) 242-3275

About Dr. Dhesi

Dr. Sandeep Dhesi grew up in Calgary and attended Western Canada high school. Early on in his childhood he was drawn towards the military and was able to realize his dream by enrolling in the Canadian Armed Forces...

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Office Hours

Monday: 7:30am - 4:00pm
Tuesday: 7:30am - 4:00pm
Wednesday: 7:30am - 4:00pm
Thursday: 7:30am - 4:00pm
Friday: 7:30am - 4:00pm

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