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*

Residential address*

City*

Province*

Postal code*

Email*

Gender*MaleFemale

Phone*

Phone (mobile)

Phone (work)

Do you have dental insurance?*

YesNo

Employer*

In case of emergency, contact (name)*

Relationship*

Phone*

Who referred you?

Dentist

MEDICAL HISTORY

Date of last medical examination

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. Do you have any other allergies?

YesNo

Specify

5. Have you ever had unusual reactions to (please select):

If yes, explain

6. Please select YES or NO for each of the current or past conditions:

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. Do you drink alcohol?

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?

Last visit:

Reason for last visit:

Last cleaning:

3. Have you ever had it? (please check):

I certify that the medical and dental information given is true and complete. Your signature will be required when you visit our office.*