Centre dentaire Pédiatrique & prosthodontique de Montréal

Personal Information (fields marked with an asterisk are mandatory)

Last name:*

First name:*

Gender:* FM

Age:

Address:

City:

Postal code:

Home phone:*

Work phone: Extention:

E-mail:*

Weight:

Height:

Birth date: Année:

Medicare Card No:

Expiry Year :

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?

If yes, provide his/her name:

Physician's phone:

Are you currently taking or have you taken any medication in the last six months

If yes, please describe them below:

Have you had a marked loss or gain of weight lately?

Are you pregnant?

Are you taking a hormonal contraceptive?

Do you or have you ever had any of the following:

Heart disease (infarction, angina, valve problems, shortness of breath)?

Rheumatic fever?

Prolonged bleeding?

Anemia?

Blood pressure?

Frequent colds or sinusitis?

Tuberculosis or lung problems?

Digestive problems?

Stomach ulcers?

Livers problems (hepatitis A, B, C or cirrhosis)?

Kidney problems?

Sexually transmitted infections (STIs)?

Diabetes?

Thyroid problems?

Skin disease?

Vision problems?

Arthritis?

Epilepsy?

Nerve problems?

Frequent headaches?

Dizziness, fainting?

Earaches?

Hay fever?

Asthma?

Do you smoke?

Have you ever had radiation treatments or chemotherapy?

Do you have acquired immunodeficiency syndrome (AIDS)?

Have you tested positive for AIDS?

Do you have any joint prostheses?

Have you ever had an allergic reaction to any of the following:

Foods?

Penicillin?

Aspirin?

Iodine?

Sulpha drugs?

Codeine?

Local anesthetic?

Others?

Explain:

Have you ever been hospitalized or undergone surgery, other than dental surgery?

If yes, specify the type of surgery and when?

Do you wish to discuss your health with the dentist?

Comments

Dental History

Date of last dental visit: 0-6 months6-12 months+ 12 months

Traitements received

Have you had any of the following dental treatments or services?

Oral hygiene demonstration?

Gum treatment?

Orthodontic treatment (braces)?

Root canal treatment?

Fillings?

Crown(s) or bridges(s)?

Full or partial prostheses?

Dental implants?

Dental x-rays?

Others?

Thank you for taking the time to fill this form. We are looking forward meeting you on your next meeting.

Centre Dentaire Pédiatrique et Prosthodontique de Montréal (en)

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Centre dentaire Pédiatrique & prosthodontique de Montréal