Last Name:
First Name:
Gender: MF
Address:
Apt:
City:
Postal Code:
Tel Home:
Cell:
Tel Work:
Date of Birth:
Day:
Month:
Year:
Email:
Who should we thank for referring you to our office ?
Dr:
Other:
What is the main reason for your visit?:
1. Are you presently under a doctor's care? YesNo
2. Attending physician: Dr:
Tel.:
3. Are you presently taking any drugs or medication, or have you taken any in the last 6 months? YesNo
If so, which ones?
Are you taking any birth control pill ? YesNo
Are you pregnant? YesNo
Are you suffering or have you ever suffered from?
5. Heart disease (stroke, angina, valvular problems, murmur) YesNo
6. Rheumatic fever YesNo
7. Prolonged bleeding YesNo
8. Anemia YesNo
9. Blood pressure YesNo
If so HighLow
10. Frequent colds or sinusitis YesNo
11. Tuberculosis or lung problems YesNo
12. Digestive problems YesNo
13. Stomach ulcer YesNo
14. Osteoporosis YesNo
15. Liver disease (hepatitis : A, B, C, cirrhosis, etc.) YesNo
16. Kidney disease YesNo
17. Sexually transmitted infections (S.T.I.) YesNo
18. Diabetes YesNo
19. Thyroid problems YesNo
20. Skin disease YesNo
21. Eye problems YesNo
22. Arthritis YesNo
23. Epilepsy YesNo
24. Nervous disorders YesNo
25. Frequent headaches YesNo
26. Dizzy spells and fainting spells YesNo
27. Earaches YesNo
28. Hay fever YesNo
29. Asthma YesNo
30. Do you smoke? YesNo
31. Are you using the electronic cigarette? YesNo
32. Have you ever had radiotherapy and/or chemotherapy (cancer)? YesNo
33. Are you an HIV carrier? YesNo
34. Do you have AIDS? YesNo
35. Do you have artificial joints (knee, hip, etc.) YesNo
36. Do you have any of the following allergies?
Food YesNo
Penicillin YesNo
Other antibiotics YesNo
Specify:
Aspirin YesNo
Iodine YesNo
Sulfonamide YesNo
Codeine YesNo
Local anasthesia YesNo
Others
Do you have any dietary restrictions (special diet, personal or religious)? If so, which ones?
Were you ever hospitalized or have you undergone surgery other than dental? If so, indicate which ones and when?
Surgery:
Please provide the information about your pharmacy.
Name:
Phone number:
What could we do to make your visit in our office as pleasant as possible?
Who is your periodontist ? None Dr. Drouin Dr. Taché Dr. Shenouda
I, the undersigned, hereby declare that I have read, understood and answered the above medical questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health.
Date:
