Case history – Soins Dentaires Côté Gilbert

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Case history Form

For 18 years and under, have parents complete

"*" indicates required fields

Patient's Name*

Date

Dentist Name*

Téléphone*

Date of last dental examination*

DD slash MM slash YYYY

Date of last dental cleaning*

DD slash MM slash YYYY

Previous treatments

Does he have cracks or pain in the jaw?*

Yes

No

Have the front teeth ever been chipped or broken?*

Yes

No

SPECIAL QUESTIONS regarding the patient:

Does he breathe through his mouth?*

Rarely

Occasionally

Always

Does he have frequent tonsillitis?*

Yes

No

Does he often have colds?*

Yes

No

Does he have difficulty chewing or swallowing?*

Yes

No

Does he suffer from headaches?*

Yes

No

Does he snore?*

Yes

No

Is he often tired, does he lack attention in class?*

Yes

No

Has he ever been treated by an allergist or ENT?*

Yes

No

If yes, when?*

By who ?*

Tonsils removed ?*

Yes

No

Vegetation removed?*

Yes

No

Age of eruption of the first primary tooth:*

Age of eruption of the first permanent tooth:*

HABITS

Thumb sucking up to the age of:

Sucking finger(s) up to the age of:

Teeth grinding:*

Yes

No

Bad swallowing:*

Yes

No

Lip sucking:*

Yes

No

Other habits (pencil in mouth, object?):*

Yes

No

Others, specify:

EXPERIENCES

Has he ever had a bad experience with a dentist?*

Yes

No

If yes which one?

Has he ever had an orthodontic examination or treatment?*

Yes

No

If yes, when?

By who? Dr.

Kind of treatments:

OTHERS

Is the patient followed by an osteopath?*

Yes

No

If yes which?

Did we miss any medical or dental issues?*

Yes

No

If yes which?

Signature of patient (or parent if minor)*

4949 Charleroi, Montréal-Nord (Qc) H1G 6L6

Suite 201 514-322-4790

info@cotegilbert201.com

Suite 301 514-328-2565

info@cotegilbert.com

Useful links

Ordre des dentistes
Ordre des hygiénistes
maboucheensante.com
Association des parodontistes

Member of jetrouvemondentiste.com

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