Citadel Health Questionnaire

Please complete this form online and hit submit - Do not print.
Last Name:*
First Name:*
 
Cell Phone: Alternate:
Address:
City: Province:
Postal Code: Date of Birth:
Health Card #:*
Email:*
 
Primary Dental Insurance (if applicable)
None   Group/Private   Community Services  
if you selected Group / Private Insurance above, please fill out this section:
Group Name:
Plan Holder Name: (Last) (First)
Relationship with Plan Holder: SELF      Spouse      Common Law      Dependant
Plan Holder's D.O.B Employer of Plan Holder
Plan / Group Number ID / Certificate Number
       
Secondary Dental Insurance (if applicable)
None   Group/Private   Community Services  
if you selected Group / Private Insurance above, please fill out this section:
Group Name:
Plan Holder Name: (Last) (First)
Relationship with Plan Holder: SELF      Spouse      Common Law      Dependant
Plan Holder's D.O.B Employer of Plan Holder
Plan / Group Number ID / Certificate Number
       
       
     
Do you have or have you ever had the following: No / Yes / Not Sure
Notes
heart condition, murmur or heart surgery?
no yes not sure
angina or chest pain?
no yes not sure
high or low blood pressure?
no yes not sure
shortness of breath climbing one flight of stairs?
no yes not sure
asthma, bronchitis or emphysema?
no yes not sure
liver disease or problems, including jaundice?
no yes not sure
infectious diseases (e.g. HIV/AIDS, Hepatitis, TB?)
no yes not sure
a bacteria resistant to antibiotics, like MRSA or VRE?
no yes not sure
CJD (mad cow) , or told you or family might be a carrier?
no yes not sure
diabetes? If yes Type 1 or Type 2?
no yes not sure
thyroid problems?
no yes not sure
taken or used any steriod-containing drugs?
no yes not sure
taken medications of osteoporosis or bone density?
no yes not sure
taken any illicit (illegal) substances other than marijuana?
no yes not sure
kidney or urinary problems?
no yes not sure
epilepsy or seizures?
no yes not sure
stroke or mini-stroke? ("TIA")?
no yes not sure
history of abnormal bleeding or bruising?
no yes not sure
stomach or duodenal ulcers?
no yes not sure
indigestion (heart burn/acid reflux), hiatus hernia, ulcers?
no yes not sure
rheumatoid arthritis or osteoarthritis?
no yes not sure
jaw joint problems ("TMD" or "TMJ")?
no yes not sure
anxiety, depression, or mental illness?
no yes not sure
malignant hyperthermia (or a family member)?
no yes not sure
Females: is there any chance you could be pregnant?
no yes not sure
Females: are you nursing/breastfeeding?
no yes not sure
Do you have sleep apnea?
no yes not sure
Do you snore loudly, or often feel tired, fatigued, or sleepy during the daytime?
no yes not sure
List your prescribed and non-prescribed medications, their doses, and how often you take them:
None See List

(include birth control, any puffers, insulin, over-the-counter drugs, alternative & herbal remedies)
List any allergies (medication, antibiotics, latex, egg, others) and your reaction to these substances:
None
List any operations/surgeries you have had, including childhood surgeries such as ear tubes or tonsils:
None
No Yes
Do you or did you ever smoke or chew tabacco regularly?
Do you still smoke or chew?    No Yes
If yes, how much?
How much alcohol do you drink per day or per week (please indicate)?
Have you been evaluated or treated in a hospital or E.R. in the last 12 months? If yes, specify reason:
No Yes
No Yes
Do you have any other health problems not listed above? Specify:
Have you or other members of your family had problems with general anaesthetics (being put to sleep for procedures) other than nausea or vomiting? For example, malignant hyperthermia. Specify:
No Yes Not Sure
Do you have any family history of bleeding problems, heart diseases, diabetes, or cancer? Specify:
No Yes Not Sure
Family Doctor Name: Phone: Location:
I certify that I have read and I understand the questions above and have completed this form to the best of my knowledge. I will not hold my surgeon, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Form completed by (please print; if not patient, state relationship);
Date
Thursday, November 21st, 2024

Citadel Privacy & Consent

ACKNOWLEDGEMENT

Citadel Privacy Statement

Having read and understood the Privacy Statement for Patients, I hereby consent to the collection, use and disclosure of my personal information as presented in the statement, subject to the restriction identified below.
Please check the appropriate box

NO RESTRICTIONS

Consent to disclose any collected information to Insurance Companies or other health care professionals as may be directly involved in your dental or medical care.

 

RESTRICTED ACCESS

My personal information shall not be provided to the following individuals or organizations:

 

RESTRICTED INFORMATION

My personal information disclosed shall not include my following personal information:



 

AUTHORIZATION (if applicable)

I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named provider. I hereby assign my benefits, payable from claims submitted electronically to continue in effect until the undersigned revokes the same.

  Check here to accept



RESPONSIBLE FINANCIAL PARTY

The name, phone number and signature of the responsible financial party is required if patient is under the age of 19.

Name:   Telephone: