Click on Calendar, type the year 'YYYY' and pick the month & date.
Dental Care & Wellness of Sonoma County


  Last name

  Mid name

  First name

Oligoscan Questionnaire

Birthday :
Blood Type: Sex: Male Female
Height: Weight:
Writing Hand Dominance: Right Left
E-Mail:
Occupation:
Activities/ Hobbies:
Please tick the appropriate-
HRT's
Biodentical
HcG-Topical
Zeolite
Oral Chelators
EDTA
DSMA
If Other, Explain:
Mineral Water (Plastic Containers) Yes No
Colloidal Silver Yes No
Bottled Water (Plastic Containers) Yes No
Tattoos Yes No
Body Piercings Yes No
Are you allergic or sensitive to any foods and/or supplements? Yes No
If Yes, Explain:
Smoke: Yes No If Yes, Type:
Alcohol: Yes No If Yes, Type:
Dental Work: Amalgams Caps Bridges Root Canals
If Other, Explain:
Diet: Raw Vegan Vegetarian Organic
If Other, Explain:
Recent Medical Tests: Mammogram CAT MRI X-Ray Colonoscopy
If Other, Explain:
For Female-
Yes No

*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)