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 :

    Parent 1's Information

    Parent 1's name:

    Tél. Office :

    Cellular :

    Parent 2's Information

    Parent 2'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 :