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Home
The clinic
- About
- The team
Services
Patient Info
Contact
Français

Home
The clinic
- About
- The team
Services
Patient Info
Contact
Français

Medical questionnaire

New patient?

Before your first appointment at the clinic, you must complete a form gathering details about your health status. To speed up the process, we invite you to fill out this form at home:

Phone

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

YOUR INFORMATIONS

This field is hidden when viewing the form

* Veuillez porter attention

First name(Required)

Last Name(Required)

Age(Required)

Date of birth(Required)

Day

Month

Year

Gender(Required)

M

F

Other

Health Ins. No.

(To be completed for children aged 10 and under)

Expiration

(MM/YYYY)

Home Tel.(Required)

Mobile

Work Tel.

Address(Required)

Address City Province Postal Code

Are you under 18?(Required)

Yes

No

Father's Name

Home Tel.(Required)

Mobile

Work Tel.

Mother's Name

Home Tel.(Required)

Mobile

Work Tel.

Who is responsible for the fees?(Required)

Father

Mother

Other

Specify Other

Email(Required)

For emergencies, call:(Required)

Name Relationship to patient

Main Tel.(Required)

Mobile

DENTAL INFORMATION

Reason for today’s visit(Required)

Last visit :(Required)

0-6 month

6-12 month

+12 month

Treatment(s) received(Required)

With panoramic radiographs (large x-ray)(Required)

Yes

No

With intraoral radiographs (small x-rays)(Required)

Yes

No

Do you fear dental treatments?(Required)

Not at all

A little

Very much

Specify(Required)

Would you like to speak privately with your dentist?(Required)

Yes

No

Reason, details and date(Required)

Are you being treated by a physician?(Required)

Yes

No

Physician's Name(Required)

Physician Tel.(Required)

Reason, details and date(Required)

Have you ever had surgery or been hospitalized?(Required)

Yes

No

Reason, details and date(Required)

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

Yes

No

Reason, details and date(Required)

Have you gained or lost a lot of weight recently?(Required)

Yes

No

Reason, details and date(Required)

Are you taking natural or homeopathic products?(Required)

Yes

No

Specify(Required)

Are you pregnant?(Required)

Yes

No

Are you breastfeeding?(Required)

Yes

No

Are you taking medication?(Required)

Yes

No

Are you taking birth control or hormones(Required)

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)(Required)

Yes

No

Heart conditions

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

Yes

No

Heart infection (endocarditis)(Required)

Yes

No

Surgery to replace or repair a valve /cusp(Required)

Yes

No

Other

Blood pressure(Required)

Yes - Low

Yes - High

No

Dizziness, fainting(Required)

Yes

No

Frequent headaches(Required)

Yes

No

Jaw pain(Required)

Yes

No

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

Yes

No

Digestive system disorders or diseases(Required)

Yes

No

Specify(Required)

Stomach disorders(Required)

Yes, Ulcer

Yes, Reflux

No

Kidney disorders(Required)

Yes

No

Diabetes(Required)

Yes

No

Thyroid disorders(Required)

Yes

No

Cancer (tumour)(Required)

Yes

No

Specify(Required)

Radiotherapy(Required)

Yes

No

Chemotherapy(Required)

Yes

No

Do you suffer from dry mouth?(Required)

Yes

No

Sexually transmitted or blood-borne infections (STBBI)(Required)

Yes

No

Specify(Required)

Skin diseases(Required)

Yes

No

Eye disorders(Required)

Yes

No

Earaches(Required)

Yes

No

Arthritis(Required)

Yes

No

Chronic pain(Required)

Yes

No

Epilepsy(Required)

Yes

No

Frequent colds or sinusitis(Required)

Yes

No

Asthma(Required)

Yes

No

Hay fever / seasonal allergies(Required)

Yes

No

Tuberculosis or lung disorders(Required)

Yes

No

Nervous system disorders or diseases(Required)

Yes

No

Mental disorders or illnesses(Required)

Yes

No

Osteoporosis(Required)

Yes

No

Annual or monthly injection(Required)

Yes

No

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

Yes

No

Allergy or manifestation with products containing:

Latex

Penicillin

Other antibiotics

Codeine

Aspirin

Sulfonamides

Anesthetic

Food

Iodine-containing products

Other

Specify(Required)

Other medical conditions that should be mentioned

Other aspects

Do you snore?(Required)

Yes

No

Do you suffer from sleep apnea?(Required)

Yes

No

Do you smoke?(Required)

Yes

No

Ex-smoker

How many cigarettes do you smoke per day?(Required)

Do you drink alcohol?(Required)

Yes

No

The number of drinks - per day, week or month:(Required)

Do you take drugs?(Required)

Yes

No

Do you take methadone?(Required)

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(Required)

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(Required)

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(Required)

Print Name(Required)

Date

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

Suite 201 514-322-4790
Suite 301 514-328-2565
info@dentaireimplantocharleroi.com

SERVICES
General Dentistry
Emergency
Implantology
Periodontics
Orthodontics
Contact
Appointment

USEFUL LINKS

Ordre des dentistes du Québec
Ordre des hygiénistes dentaires du Québec

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