Medical Questionnaire – Soins Dentaires Côté Gilbert

YOUR INFORMATIONS

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* Veuillez porter attention

First name*

Last Name*

Age*

Date of birth*

Gender*

M
F
Other

Health Ins. No.

(To be completed for children aged 10 and under)

Expiration

(MM/YYYY)

Home Tel.*

Mobile

Work Tel.

Address*

Address City Province Postal Code

Are you under 18?*

Yes
No

Father's Name

Home Tel.*

Mobile

Work Tel.

Mother's Name

Home Tel.*

Mobile

Work Tel.

Who is responsible for the fees?*

Father
Mother
Other

Specify Other

Email*

For emergencies, call:*

Name Relationship to patient

Main Tel.*

Mobile

DENTAL INFORMATION

Reason for today’s visit*

Last visit :*

0-6 month
6-12 month
+12 month

Treatment(s) received*

With panoramic radiographs (large x-ray)*

Yes
No

With intraoral radiographs (small x-rays)*

Yes
No

Do you fear dental treatments?*

Not at all
A little
Very much

Specify*

Would you like to speak privately with your dentist?*

Yes
No

Reason, details and date*

Are you being treated by a physician?*

Yes
No

Physician's Name*

Physician Tel.*

Reason, details and date*

Have you ever had surgery or been hospitalized?*

Yes
No

Reason, details and date*

Do you have joint prostheses (hip, knee, etc.)?*

Yes
No

Reason, details and date*

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

Yes
No

Reason, details and date*

Are you taking natural or homeopathic products?*

Yes
No

Specify*

Are you pregnant?*

Yes
No

Are you breastfeeding?*

Yes
No

Are you taking medication?*

Yes
No

Are you taking birth control or hormones*

Yes birth control
Yes hormones
No

Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months

YOUR CURRENT CONDITION

Blood disorders

(hemophilia, anemia, prolonged bleeding)*

Yes
No

Heart conditions

Infarction (heart attack), angina, surgery, etc.*

Yes
No

Heart infection (endocarditis)*

Yes
No

Surgery to replace or repair a valve /cusp*

Yes
No

Other

Blood pressure*

Yes - Low
Yes - High
No

Dizziness, fainting*

Yes
No

Frequent headaches*

Yes
No

Jaw pain*

Yes
No

Liver disorders (hepatitis A, B, C. cirrhosis, etc.)*

Yes
No

Digestive system disorders or diseases*

Yes
No

Specify*

Stomach disorders*

Yes, Ulcer
Yes, Reflux
No

Kidney disorders*

Yes
No

Diabetes*

Yes
No

Thyroid disorders*

Yes
No

Cancer (tumour)*

Yes
No

Specify*

Radiotherapy*

Yes
No

Chemotherapy*

Yes
No

Do you suffer from dry mouth?*

Yes
No

Sexually transmitted or blood-borne infections (STBBI)*

Yes
No

Specify*

Skin diseases*

Yes
No

Eye disorders*

Yes
No

Earaches*

Yes
No

Arthritis*

Yes
No

Chronic pain*

Yes
No

Epilepsy*

Yes
No

Frequent colds or sinusitis*

Yes
No

Asthma*

Yes
No

Hay fever / seasonal allergies*

Yes
No

Tuberculosis or lung disorders*

Yes
No

Nervous system disorders or diseases*

Yes
No

Mental disorders or illnesses*

Yes
No

Osteoporosis*

Yes
No

Annual or monthly injection*

Yes
No

Prevention / treatment (e.g.: tablets)*

Yes
No

Allergy or manifestation with products containing:

Specify*

Other medical conditions that should be mentioned

Other aspects

Do you snore?*

Yes
No

Do you suffer from sleep apnea?*

Yes
No

Do you smoke?*

Yes
No
Ex-smoker

How many cigarettes do you smoke per day?*

Do you drink alcohol?*

Yes
No

The number of drinks - per day, week or month:*

Do you take drugs?*

Yes
No

Do you take methadone?*

Yes
No

ACCEPTANCE

Please consult the following documents before your acceptance and signature:

Consentement - Patient 14 ans et moins
Consentement - Patient 14 ans et plus
Politique de confidentialité

Dental and medical history acceptance*

I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.

Acceptance of Collection, use, and disclosure of personal information*

I hereby give my consent to the collection, use and disclosure of my personal information by Soins Dentaire Côté Gilbert for the purpose of providing dental services.

Signature of patient or parent*

Print Name*

Date

Name

This field is for validation purposes and should be left unchanged.

Medical Form for New Patients

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