Confidential medical form

Before coming to your first appointment at the dental clinic, we recommend that you fill out a form that will collect details about your health. Filling it out in the comfort of your home will also speed up the process in the clinic.

    Medical history

    Gender*

    FM
    Last Name*

    First Name *

    Address*

    City*

    Postal code*

    Home Phone*

    Work phone

    Cellphone*

    Email*

    Birth Date*

    Height*

    Weight*

    Health Insurance Number*

    Expiration Date:

    If you are under 18, name of a parent or legal guardian:

    c

    In case of emergency, please contact

    Are you receiving social assistance?

    Reason for visit

    Referred by

    1. Are you under a physician’s care now ?



    2.  Are you taking any medications, or have you taken any in the last 6 months?
    YesNo

    3. Are you taking natural or homeopathic products
    YesNo

    Oral Contraceptives (Birth Control Pills) ?
    YesNo

    Hormones?
    YesNo

    4. Have you significantly gained or lost weight lately?
    YesNo

    5. Are you pregnant ?
    YesNo

    Nursing ?
    YesNo

    Do you have, or have you had, any of the following

    1. 6. Heart Disease
      YesNo
      1. 6.1 Heart Attack
        YesNo
      2. 6.2 Angina
        YesNo
      3. 6.3 Valve Problems
        YesNo
      4. 6.4 Heart Murmur
        YesNo
      5. 6.5 Congenital Heart Disease
        YesNo
      6. 6.6 Chest Pain on Exertion
        YesNo
      7. 6.7 Coronary Insufficiency
        YesNo

    7. 7. Blood Transfusion
    YesNo

    8. Rheumatic Fever
    YesNo

    9. Blood Disorders
    YesNo

    1. 9.1 Haemophilia
      YesNo
    2. 9.2 Light Blood
      YesNo
    3. 9.3 Anemia
      YesNo
    4. 9.4 Abnormal Bleeding or Hemorrhage during surgery
      YesNo
    5. 9.5 Other
      YesNo

    10. Blood Pressure
    NormalLowHigh

    11. Frequent Colds or Sinusitis
    YesNo

    12. Sudden Loss of Consciousness
    YesNo

    13. Lung Problems
    YesNo

    1. 13.1 Chronic Bronchitis
      YesNo
    2. 13.2 Pneumonia
      YesNo
    3. 13.3 Emphysema
      YesNo
    4. 13.4 Tuberculosis
      YesNo

    14. Sinusitis
    YesNo

    15. Jaundice
    YesNo

    16. Hepatitis B
    YesNo

    17. Hepatitis C
    YesNo

    18. Digestive Disorders
    YesNo

    Please explain :

    19. Stomach ulcers
    YesNo

    20. Liver Disease (Hepatitis : virus A,
    B, C, cirrhosis, etc.)
    YesNo

    21. Kidney Disorder
    YesNo

    22. Frequent Urination
    YesNo

    23. Sexually Transmitted Infection (STI)

    YesNo

    24. Diabetes
    YesNo

    25. Thyroid Disorder
    YesNo

    26. Skin Disease
    YesNo

    27. Stroke
    YesNo

    28. Use of Bisphosphonates
    YesNo

    29. Vision Problems (eyes)
    YesNo

    30. Arthritis
    YesNo

    31. Osteoporosis
    YesNo

    32. Epilepsy
    YesNo

    33. Neural Disorder
    YesNo

    34. Psychiatric Disease
    YesNo

    35. Frequent Headaches
    YesNo

    37. Dizziness/Fainting Spells
    YesNo

    38. Earaches
    YesNo

    38. Hay Fever
    YesNo

    39. Asthma
    YesNo

    40. Do you smoke any tobacco products?
    YesNo

    41. Have you ever been given radiation therapy and/or chemotherapy treatment? (tumor)
    YesNo

    42. Are you suffering from AIDS?
    YesNo

    43. Are you HIV-positive?
    YesNo

    44. Do you have joint prostheses? 0
    YesNo

    45. Do you snore or have you ever been told you were snoring ?
    YesNo

    46. Have you ever had an allergic reaction or else to any of these following products:

    46.1 Latex
    YesNo

    46.2 Food
    YesNo

    46.3 Iodin
    YesNo

    46.4 Aspirin
    YesNo

    46.5 Sulfa Drugs
    YesNo

    46.6 Penicillin
    YesNo

    46.7 Codein
    YesNo

    46.8 Other antibiotics
    YesNo

    46.9 Local Anesthetics
    YesNo

    46.10 Other
    YesNo

    47. Are you taking drugs ?
    YesNo

    48. Are you consuming alcohol ?
    LittleModeratelySignificantly

    49. Have you ever been hospitalized or undergone surgery other than dental
    YesNo

    If yes, explain and tell us when

    50. Do you fear getting dental care ?
    A littleA lotNot at all

    51. Would you like to discuss your health privately with your dentist?
    YesNo

    52. Do you have dental insurance?
    YesNo

    53. Insurance Company

    54. Name of Holder

    55. Date of birth of Holder

    56. Policy or Contract Number

    57. Certificate or Identifying Number

    58. How did you hear about us?

    Yellow pagesInternetFlyersMedia pagesOur clinic's window displaysI am already a patientI have been referred by one of your existing patients

    Dental History

    59. Last visit to the dentist:
    During the last 12 monthsMore than 12 months

    60. Have you had the following dental treatments or services?

    1. 60.1 Oral hygiene demonstration
      YesNo
    2. 60.2 Orthodontic treatment (braces)
      YesNo
    3. 60.3 Fillings (repairs)
      YesNo
    4. 60.4 Complete or partial dentures
      YesNo
    5. 60.5 Dental implants
      YesNo
    6. 60.6 Gum treatment
      YesNo
    7. 60.7 Treatment of a canal
      YesNo
    8. 60.8 Crown(s) or bridge(s)
      YesNo
    9. 60.9 Oral surgery treatment or extraction
      YesNo
    10. 60.10 Dental x-rays
      YesNo
    11. 60.11 Other
      YesNo

      I authorize Centre Dentaire De La Gare to communicate with my clinic for my file and radiographs transferring.