Confidential Medical-Dental Questionnaire

Patient information

Man

Women

Other

Last name of the patient*

First name of the patient*

Email of the patient*

Address

Adress and apartment*

City*

Postal code*

Home phone

Cell phone

Office phone

Post

Birth date

Year*

Month*

Day*

If you are under 14, write the name of the parent

OR guardian

Dental informations

Reason for visit*

Do you fear dental treatments:*

A little

A lot

Not at all

Last visit:*

0 to 6 months

6 to 12 months

+ 12 months

Treatment(s) received:

With panoramic dental radiography (large X-ray)*

Yes

With intraoral dental X-rays (small x-rays)*

Yes

Have you ever had dental treatments such as

Oral hygiene demonstration*

Yes

Gum treatment*

Yes

Orthodontic Treatment*

Yes

Root canal treatment*

Yes

Shutter*

Yes

Crown and / or bridge*

Yes

The tonsils were they removed*

Yes

Have the adenoids (vegetations) been removed?*

Yes

Do you have a nasal septum deviation*

Yes

Do you have difficulty breathing through the nose*

Yes

Have you ever received a hit on your teeth?*

Yes

Do you suck your thumb or finger?*

Yes

Complete and / or partial dentures*

Yes

Oral surgery or extractions Treatment*

Yes

Dental implants*

Yes

Dental x-rays*

Yes

Do you bite your nails?*

Yes

Do you get annoyed about your teeth?*

Yes

Do you grind your teeth at night?*

Yes

Did you have a consultation with an orthodontist? If so, which?*

Yes

Information on growth (for children 10-14 years)

Is your child in active growth period?*

Yes

N/A

Does your child seem to have reached puberty?*

Yes

N/A

Girls only*

Are you taking birth control pills (oral contraceptives)?*

Yes

Do you take hormones? Specify:*

Yes

Are you pregnant?*

Yes

Do you breastfeed?*

Yes

Medical history

Do you have a family doctor?*

Yes

Doctor's name

Doctor's phone

Post

Are you under the care of a doctor? If so, reason:*

Yes

Doctor's name

Doctor's phone

Post

Are you taking natural or homeopathic products?*

Yes

Have you gained or lost a lot of weight lately?*

Yes

Are you taking any medications or have you taken any in the last 6 months? If yes, which ones:*

Yes

Have you ever been hospitalized or undergone surgery other than dental? If yes, specify*

Yes

Have you suffered or are you suffering from:

Cardiac disorders (heart attack, angina, endocarditis, valve problems, breath)*

Yes

Rheumatic fever*

Yes

Jaw pain*

Yes

Dryness of the mouth*

Yes

Blood problems

Hemophilia*

Yes

Prolonged bleeding*

Yes

Thin blood*

Yes

Blood pressure (High or low). If yes, specify*

Yes

Anemia*

Yes

Other, specify*

Yes

Frequent colds or sinusitis*

Yes

Pulmonary tuberculosis or problems*

Yes

Digestive disorders, specify*

Yes

Stomach ulcer*

Yes

Liver problems (hepatitis: viruses A, B, C, etc.)*

Yes

Kidney disorders*

Yes

Sexually transmitted diseases (STDs)*

Yes

Diabetes*

Non

Type 1

Type 2

Thyroid problems*

Yes

Skin disease*

Yes

Eye problems*

Yes

Epilepsy*

Yes

Nervous system disorders or diseases*

Yes

Mental disorders or illnesses, if so specify*

Yes

Dizziness, fainting*

Yes

Earaches*

Yes

Hay fever*

Yes

Asthma*

Yes

Arthritis*

Yes

Osteoporosis*

Yes

Are you taking any medication for bone density?*

Yes

Chronic Pain*

Yes

Have you ever had radiation treatment and / or chemotherapy (tumor)?*

Yes

Do you have any artificial joints (hip, knee, etc.)?*

Yes

Have you ever had an allergic reaction or ather to the following products:

Latex*

Yes

Food. If yes, which ones:*

Yes

Iodine*

Yes

Aspirin*

Yes

Sulfonamides*

Yes

Penicillin*

Yes

Codeine*

Yes

Other antibiotics or medications. If yes, which ones:*

Yes

Local anesthesia*

Yes

Other, specify*

Yes

Would you like to discuss your health with your private dentist?*

Yes

Other aspects

Do you wake up tired in the morning and/or feel tired during the day?*

Yes

Do you snore, or has anyone ever told you that you snore?*

Yes

Do you suffer from sleep apnea?*

Yes

Do you smoke? If yes, how much per day*

Yes

Do you consume alcohol?*

Little or no

In moderation

A lot

Do you use drugs? If yes, which ones?*

Yes

Do you use cannabis?

Yes

Do you take methadone?*

Yes

Note or other medical conditions to mention

Is there any other information we haven't asked for that might be useful? If so, please explain:*

Yes

Consent Form for the Collection and Use of Personal Information

I, the undersigned, ,
acting as the legal guardian of , hereby declare that I have read, understood, informed myself, and answered the above medical-dental questionnaire to the best of my knowledge. I hereby undertake to inform you of any change in the health condition of .

I, the undersigned, , hereby declare that I have read, understood, informed myself, and answered the above medical-dental questionnaire to the best of my knowledge.

Name of the parent or legal guardian:

I hereby undertake to inform you of any change in my health condition.

I, the undersigned, , hereby declare that I have read, understood, informed myself, and answered the above medical-dental questionnaire to the best of my knowledge. I hereby undertake to inform you of any change in my health condition.

Patient or guardian signature

Delete signature

You must sign the questionnaire

Si le patient est un mineur de moins de 14 ans : le titulaire de l’autorité parentale (incluant le parent) ou le tuteur doit signer. Si le patient est un mineur de 14 ans ou plus : le mineur lui-même peut signer, ou bien le titulaire de l’autorité parentale (incluant le parent) ou le tuteur.

Fields marked with an asterisk (*) are required.

Confidential Medical-Dental Questionnaire

Confidential and Secure Health Questionnaire

Patient information

Address

Birth date

Dental informations

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

Have you ever had an allergic reaction or ather to the following products:

Other aspects

Consent Form for the Collection and Use of Personal Information