VOLUNTEER INFORMATION SHEET
(All information strictly CONFIDENTIAL once completed)
"*" indicates that the information requested is mandatory
Personal:
Name:
(last)*
(first)*
(middle)
Address:
(street)*
(city)*
(postal code)*
Phone:
(Home)*
(Work) (ext)
(Alternate)
Sex:
Please Select One
Male
Female
(M/F)*
Date of Birth:
Please Select One
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
(month)*
Please Select One
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(day)*
(year)*
Medical:
Do you smoke:*
No
Yes
If
Yes
,type
(cigarettes/pipe/other-describe)
(describe)
How many cigarettes
per day
per week
per month
Do you have any of the following conditions? For each condition describe in proper box
Allergies*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
High Blood Pressure*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Diabetes*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Asthma*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Arthritis*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Hepatitis*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Rheumatic Fever*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Other medical conditions and/or medications*
No
Yes
Description(How long have you had it? How severe?)
Medicine
Frequency
Oral contraception
(Women only)
No
Yes
If,yes please give me name
Dental:
Number of Natural Teeth:*
(Humans normally have 28 teeth and 4 wisdom teeth
for a total of 32.Do not count teeth with caps,but
include teeth with fillings and/or root canals).
Orthodontic Appliances:
Please select one
Lingual Wires
Retainers
Braces
Dentures:
Upper :
(Full
Partial
)
Lower :
(Full
Partial
)
Heavily bleeding gums:
(If applicable,describe)
Cold sores and cankers:
(If applicable,describe and give frequency of occurence)
Tooth Hypersensitivity:
Normal biting
Hot(food/drinks)
Cold(food/drinks)
Sweet or Sour
Severity:
Low
Medium
High
Treatment:
Other Dental Conditions:
General:
Is there
ANYTHING
else we should know about your
ORAL
or
GENERAL
health?*
No
Yes
If YES,please describe:
The information provided here is complete and truthful to the best of my knowledge I agree to update this information upon request.In the future I will advise BioSci of any dental or medical changes.I agree to inform BioSci of any dental or medical experimental trial(s) that I may participate in.
Date:
Thank You (-: