Medical Form

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Date of appointment :

Medical and Dental Questionnaire

Last Name :
First Name :
Sex :

Address

No. :
Street :
App. :
City :
Postal Code:
Tel. Res. :
Tel. Office :
Cellular :
Age :
Date of birth :
Height :
Weight :

Mother's Information

Mother's name:
Tél. Office :
Cellular :

Father's Information

Father's name :
Tel. Office :
Cellular :

Secondary Address

No. :
Street :
App. :
City :
Postal Code :
Are you the person responsible for the payment :
If not, name of the person responsible :
Relationship with the patient :
Do you carry a dental insurance plan :
Name of the person who referred you to us :
Name of your dentist :

MEDICAL HISTORY

Are you suffering or have you ever suffered from :

Arthritis :
Anemia :
Asthma :
Tuberculosis :
Diabetes :
Epilepsy :
Earaches :
Fainting spells :
Rheumatic fever :
Heart disease :
Dizziness :
Kidney/liver disease :
Radiation treatment (cancer) :
Frequent headaches :
Thyroid problem :
High or low blood pressure :
Nervous disorders :
Osteoporosis :
Do you take any bisphosphonates ?
Do you snore or have you been told you do ?
Are you presently under a doctor's care ?
If yes, for what reason :
Name of your physician :
Are you taking any medication or have you taken any in the last 6 months ?
If so, which :
Are you HIV positive ?
Do you bleed abnormally when you are injured ?
Do you have frequent colds ?
Are your tonsils or / and adenoids removed ?
If yes, when ?
Do you suffer from any allergies (respiratory, food or dietary, medication or other) ?
If so, specify ?
Please let us know any further information regarding your medical history :

DENTAL HISTORY

Date of your last dentist's examination:
How many times a year do you visit your dentist ?
How many times a day do you brush your teeth ?
Have you had any accident to your face ?
Have you had any injuries to your head or jaw bones ?
Did you ever have an orthodontic treatment ?
Do you hear any cracking noises in your jaw joints ?
Do you experience painful or bleeding gums ?
Have you undergone treatments for your gums (grafts, deep scaling) ?
Do you bite your finger nails ?
Do you grind grind your teeth ?
Do you chew gum for more than 15 minutes per day ?
Do you still suck your thumb ?
Does the esthetic appearance of your teeth bother you and do you wish to correct it ?
Have you ever seen a speech therapist ?
Has any other member of the family had an orthodontic treatment ?
If yes, indicate the name of the professional who did the correction :