Personal Information (fields marked with an asterisk are mandatory)
Last name :*
First name :*
Gender :*
Address :
City :
Postal code :
Home telephone :*
Work telephone :
E-mail :*
Weight :
kilos
livres
Height :
meters
foot
Birth date :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
january
february
march
april
may
june
july
august
september
october
november
december
Medicare Card No :
Expiry :
Année :
january
february
march
april
may
june
july
august
september
october
november
december
If child, parent's name :
In case of emergency call :
Reason for visiting us :
Medical History
Are you currently under the care of a physician ? :
no
yes
If yes, provide his/her name :
Physician's Tel :
Are you currently taking or have you taken any medication in the last six months?
no
yes
If yes, please descrive them below:
Did you have a weight loss or gain lately ?
no
yes
Are you pregnant?
nn
yes
no
yes
Do you or have you ever had any of the following:
Heart disease (infarction, angina, valve problems, shortness of breath)?
no
yes
Rheumatic fever?
no
yes
no
yes
no
yes
Blood pressure?
normal
high
low
no
yes
Tuberculosis or lung problems?
no
yes
no
yes
Stomach ulcers?
no
yes
Liver problems (hepatitis A, B, C or cirrhosis)
no
yes
no
yes
Sexually transmitted infections (STIs)?
no
yes
no
yes
Thyroid problems?
no
yes
no
yes
Vision problems?
no
yes
no
yes
no
yes
Nerve problems?
no
yes
no
yes
Dizziness, fainting?
no
yes
no
yes
Hay fever?
no
yes
no
yes
no
yes
sometimes
Have you ever had radiation treatments or chemotherapy?
no
yes
Do you have acquired immunodeficiency syndrome (AIDS)?
no
yes
Have you tested positive for AIDS?
no
yes
Do you have any joint prostheses?
no
yes
Have you ever had an allergic reaction to any of the following:
Foods
no
yes
no
yes
no
yes
no
yes
Sulpha drugs
no
yes
no
yes
no
yes
Others:
no
yes
Explain:
Have you ever been hospitalized or undergone surgery, other than dental surgery?
no
yes
If yes, specify the type of surgery and when:
Do you wish to discuss your health with the dentist?
no
yes
Comments
Dental History
Date of last dental visit:
Treatment received
Have you had any of the following dental treatments or services?
Oral hygiene demonstration?
no
yes
no
yes
Orthodontic treatment (braces)?
no
yes
no
yes
Fillings?
no
yes
no
yes
Full or partial prostheses?
no
yes
Dental surgery or extraction?
no
yes
Dental implants?
no
yes
no
yes
no
yes
