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Dr Simon Touchan
Dr Miller Smith
Dr Graham Cobb
Dr Brad Fisher
Dr Brett Habijanac
Dr Tuan G. Bui
Dr Tanya Rouleau
What is OMS?
Scheduling
OUR CLINIC
PROCEDURES & SERVICES
Anesthesia
Wisdom Teeth Extractions
Teeth Extractions
Bone Grafting
Dental Implants
Exposure of Impacted Teeth
Head and Neck Pathology
Facial Trauma and Reconstruction
Surgical Treatment of TMJ Disorders
Orthognathic Surgery
Surgical Treatment of Sleep Apnea
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Confidential Health Questionnaire
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REFERRAL FORM
CONTACT US
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Confidential
Health Questionnaire
Full Name
First
Last
Email
Date of Birth
Month
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Are you experiencing any pain at this time?
Yes
No
Do you clench or grind your teeth?
Yes
No
Have you had any problems with local anaesthetic (freezing)?
Yes
No
Do you have any allergies or unusual reations to any medications or foods? (please list)
Yes
No
If yes, (explain)
Please list all medications / pills / herbal medicines you are taking or have been taking including their frequency & dosage
Please list any disabilities
Have you had any previous serious illness?
Yes
No
If yes, (explain)
Have you ever had a general anesthetic or previous surgeries?
Yes
No
If yes, (please list)
Have you or any member of your family ever had a bad reaction to general anesthetic?
Yes
No
Please specify which family member had this reaction. Exactly what was the bad reaction?
Do you have high blood pressure?
Yes
No
Have you ever had rheumatic fever or scarlet fever?
Yes
No
Do you have a heart murmur?
Yes
No
Do you have any implants in your body? (heart valve, knee, hip)
Yes
No
If yes, has your physician recommended that you receive preventative antibiotics before dental work?
Yes
No
If yes, what is the recommendation specifically?
Do you have any liver disease?
Yes
No
Do you have any kidney disease?
Yes
No
Do you have diabetes?
Yes
No
Do you have any breathing or lung problems? (bronchitis, etc.)
Yes
No
Do you have asthma?
Yes
No
If yes, medications :
Last Asthma Attack
Month
1
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12
Day
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Last Hospitalization
Month
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12
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2019
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2015
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2013
2012
2011
2010
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2008
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1967
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1951
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have you had radiation treatment for cancer?
Yes
No
Do you suffer from osteoporosis?
Yes
No
Have you ever been on bisphosphonates? (ie. fosamax, didrocal, actonel)
Yes
No
If yes, for how many years have you been on it
Month
1
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Year
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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2007
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1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Do you suffer from reflux or other gastrointestinal disease?
Yes
No
Do you have a history of glaucoma?
Yes
No
Have you ever been tested for A.I.D.S. / HIV?
Yes
No
When?
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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3
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30
31
Year
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2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1991
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1989
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1982
1981
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1978
1977
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1969
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1951
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Results
Have you ever been tested for Hepatitis A, B or C ?
Yes
No
When?
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
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1972
1971
1970
1969
1968
1967
1966
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1964
1963
1962
1961
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1957
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1953
1952
1951
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1949
1948
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Results
Have you ever had a bleeding problem or blood disorder?
Yes
No
If yes, please specify
Are you taking blood thinners? (anticoagulants)
Yes
No
Have you ever had a seizure?
Yes
No
When?
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
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14
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17
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25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Results
Do you think you might be pregnant ?
Yes
No
Are you nursing?
Yes
No
Do you smoke?
Yes
No
If so, how much?
Are you suffering from any psychological or mental disorders and/or handicaps?
Yes
No
Please clarify the nature of your disorder / handicap
Is it well controlled?
Yes
No
Do you drink alcohol?
Yes
No
If yes, what is your average intake per week? (number of Alcoholic Beverages)
Do your suffer from sleep apnea?
Yes
No
Height
Weight
Signature
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