Medical Questionnaire　Healthy Life Dental Clinic
Please answer the simple questions.
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Mail Adress *
Name *
Date of birth
MM
/
DD
/
YYYY
Mobile phone Number *
Home or Office phone number
Address *
Occupation *
How did you find out us? (Multiple answers allowed) *
Required
What are your symptoms?(Multiple answers allowed) *
Required
When did you go to the Dentist last time? *
Have you ever been scared or bad feeling during dental treatment? *
What is your preference for treatment?(Multiple answers allowed) *
Required
What time is better to come?(Multiple answers allowed) *
Required
Treatment Policy(Multiple answers allowed) *
Required
Are you interested in "healthy life program" Dental checkup??(you can know the plan and cost through whole body and mouth checkup)
Clear selection
What are you interested in? (multiple answers allowed)
Do you have any diagnosed disease?(multiple answers allowed)
Are you currently taking medication?(Multiple answers allowed) *
Required
Do you have any allergy?(Multiple answers allowed) *
Required
When do you brush your teeth?(multiple answers allowed)
How long does it take when you brush your teeth?
Do you use cleaning devices except toothbrush?
Which supplements do you take if you do?(multiple answers allowed)
Do you smoke?
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To smokers, How often do you smoke a week?
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How long do you sleep usually?
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How many times do you eat in a day?
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About Appetite(multiple answers allowed)
I eat very often...(multiple answers allowed)
How much do you take some Water?
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What kind of drinks do you take often?(multiple answers allowed)
What kind of food do you take often?(multiple answers allowed) *
Required
Do you drink alcohol? *
How often do you take alcohol a week?
How often do you take some sweets a day? *
When do you feel like taking some sweets a day?(multiple answers allowed) *
Required
How often do you take some fruits a day? *
Kindly pick out relevant parts of your mouth condition.(multiple answers allowed)
Kindly pick out of clench and grind your teeth.(multiple answers allowed)
Please tell me about you.(multiple answers allowed)
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