Medical Intake

ASURA Longevity Dentistry – Digital Medical History Questionnaire

Step 1 of 119%

Patient Information

Full Name

Preferred Name / Nickname

Date of Birth

Age

Mobile Number

GP Name

Physician/Specialist Name

Medical specialist involved in care

Referring clinician (optional)

When was your most recent physical examination?

What is the purpose of your appointment at ASURA?

General assessment

Smile improvement

Bite concerns

Jaw pain / TMJ

Worn teeth

Implant assessment

Full mouth rehabilitation

Orthodontics

Sleep / snoring concerns

Airway assessment

Longevity dentistry

Second opinion

Other

What is your estimate of your general health?

Excellent

Good

Fair

Poor

ASURA Longevity Dentistry

Medical Health & Wellness Screening Summary

Patient: N/A

Date: 6/27/2026

1. Thank You

Thank you for completing your medical history questionnaire. Your responses help us better understand your health profile and ensure treatment is planned safely and comprehensively. This questionnaire is a screening tool and does not replace medical diagnosis.

2. Your Responses Summary

General Health Rating: N/A

Known Allergies: None

Current Medications:

None

3. Risk Profile

Your answers suggest some medical considerations that may benefit from further review during your consultation.

Overall Medical Risk: Low

ASA Classification: ASA 1

STOP-BANG Score: 0

Epworth Score: 0

Disclaimer

This screening tool does not provide diagnosis and is intended to support discussion with your clinician.