Medical Questionnaire Use our secure online form to complete your medical questionnaire. It's simple, easy and quick! This questionnaire will allow the periodontist and his team to provide the best possible care and to reduce the risk of medical complication. It's in the patient's interest to respond carefully and to advise of any change in their medical condition. Person responsible for the protection of personal information: Julie Hayes 819-525-9255 PERSONAL INFORMATION * = required fields Last name* First name* Date of birth* Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916 Residential address* City* Province* Postal code* Email* Gender*MaleFemale Phone* Phone (mobile) Phone (work) Do you have dental insurance?* YesNo Nom de la compagnie d’assurance Last name of beneficiary First name of beneficiary Numéro d’identification Policy number Beneficiary's date of birth Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916 Do you have second dental insurance? (Optional) YesNo Nom de la compagnie d’assurance Last name of beneficiary First name of beneficiary Numéro d’identification Policy number Beneficiary's date of birth Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916 En cas d’urgence, contacter (nom)* Relationship* Phone* Who referred you? Dentist MEDICAL HISTORY Date of last medical examination Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916 Family doctor 1. Do you take any medications or natural products? YesNo Specify 2. Has there been any other medications in the past year? YesNo Specify 3. Are you allergic to any medications? YesNo Specify 4. Avez-vous d’autres allergies? YesNo Specify 5. Have you ever had unusual reactions to (please select): local anesthesiapenicilliniodinesulfonamide (sulfa)other medication If yes, explain 6. Please select YES or NO for each of the current or past conditions: Are you currently followed by a doctor? YesNo Have you ever been hospitalized? YesNo Blood problems (hemophilia, anemia, prolonged bleeding) YesNo Heart conditions Infarction, angina, heart surgery YesNo Heart infection (endocarditis) YesNo Repair / valve replacement / stent YesNo Blood pressure (high pressure) YesNo Blood pressure (low pressure) YesNo Stroke YesNo Dizziness, fainting YesNo Frequent headaches YesNo Liver problem (hepatitis A, B, C, cirrhosis, etc.) YesNo Disorders or diseases of the digestive system YesNo Troubles d’estomac (Ulcère ou reflux) YesNo Kidney disorders or diseases YesNo Diabetes (Type 1 or 2) YesNo Thyroid disorders (Hyper or hypo) YesNo Remplacement d’articulation (genou/hanche) YesNo Transplantation d’organe / implant médical YesNo Sexually Transmitted and Bloodborne Infection (STBBI) YesNo Skin diseases YesNo Eye problems (eyes) YesNo Maux d’oreilles YesNo Arthritis YesNo Osteoporosis YesNo Prevention / treatment (tablet) YesNo Annual or monthly injection YesNo Chronic pain YesNo Cholesterol YesNo Epilepsy YesNo Nervous system disorders / diseases YesNo Psychiatric disorders / diseases YesNo Frequent colds or sinusitis YesNo Tuberculosis / lung problems YesNo Asthma YesNo Hay fever / seasonal allergies YesNo Cancer (tumor) YesNo Radiotherapy YesNo Chemotherapy YesNo Anxiety YesNo Substance addiction YesNo Do you use any drugs YesNo Is there a disease, physical condition, or problem that is not above and that we should know about? YesNo Specify 7. Do you smoke? YesNoEx-smoker If yes, cig./day and nb. years 8. Consommez-vous de l’alcool ? YesNo Frequency: 9. a) Female only: Are you pregnant? YesNo Are you breastfeeding? YesNo Birth control pill? YesNo b) Male only: Do you have prostate problems? YesNo 10. Have you ever had any type of dermal / cosmetic fillers? YesNo Specify DENTAL HISTORY 1. Please check YES or NO for each of the following questions: Are your gums bleeding? YesNo Grind or clench your teeth day or night? YesNo Does your breath sometimes bother you? YesNo 2. How often do you visit your dentist? 3-4 months6 months9 months12 monthsirregularlyother Last visit: Reason for last visit: Last cleaning: 3. Have you ever had it? (please check): Oral surgeryPeriodontal treatmentOrthodontic treatmentOcclusal guardOther device I certify that the medical and dental information given is true and complete. Your signature will be required when you visit our office.*
