Questionnaire
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Dr. Barry M. Montag, DDS

294 South University Drive Plantation, FL 33324 954-475-8000
Name

last

first

middle

Address
City                                                  State                             Zip
Date of Birth                              Sex  M / F              Home Phone                             Cell Phone
Married  Y / N                      if yes Spouse Name                                 
Occupation                                                    Place of Employment
Dental Insurance Name                                           S.S. Number
Email Address
Business Phone                                                       Referred By
In the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

1.  Has there been any change in your general health within the past five    years?                     Y / N

2.  Are you now under the care of a physician?                     Y / N
          If so, what is the condition is being treated? _______________________

3.  Name and address of physician          ________________________________

4.  Have you been hospitalized or had a serious illness within the past five years?                     Y / N

5.  Circle any of the following diseases or problems you have had.
Rheumatic Fever Low Blood Pressure Arteriosclerosis
Heart Trouble High Blood Pressure Sinus Trouble
Stroke Allergy Fainting Spells / Seizures
Asthma / Hay Fever Hives / Skin Rash Liver Disease
Diabetes Hepatitis / Jaundice Stomach Ulcers
Arthritis Tuberculosis Glaucoma
Kidney Trouble Venereal Disease Mitral Valve Prolapse
Heart Attack Blood Disorder / Anemia Other _________________

6.  Have you ever tested positive for the AIDS virus?                     Y / N

7.  Have you ever had surgery or x-ray treatment for a tumor, growth, or condition of your mouth or lips?                    Y / N

8.  Have you had abnormal bleeding associated with previous extractions?                    Y / N
9.  Are you taking any drug or medicine at the present time?                    Y / N
          If so, what    _____________________________________________________
10.  Circle any you are allergic to or react adversely to:
Local Anesthetics Penicillin Sulfa Drugs
Barbiturates, sedatives Aspirin Codeine
Sleeping Pills Other   ________________

11.  Do have any disease, condition, or problem not listed above that you think I should know about?                    Y / N
If so, explain ______________________________________________________

12.  Are you pregnant?                    Y / N

13.  Date of your last dental treatment  __________________           

14.  Reason for today's visit  ___________________________________________

15.  IS THERE ANYTHING ABOUT YOUR SMILE THAT DISPLEASES YOU?                    Y / N
If so, explain  ___________________________________________________

Date ____________    Signature __________________________________