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CONFIDENTIAL MEDICAL-DENTAL QUESTIONNAIRE

A patient’s file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office, where only the dentist and his or her staff have access to it. Patients are also entitled to acess their file and make corrections.

This questionnaire will help the dentist and his or her staff provide the best possible care and reduce the risk of medical complications. It is in the patient’s best interest to carefully fill it out and notify the dentist of any change in their health condition.

Personal Information
Contact Information
Dental Information

Medical history

Yes No

1. Are you being treated by a physician?

2. Have you ever had surgery or been hospitalized?

3. Do you have joint prostheses (hip, knee, etc. )?

4. Are you pregnant?

5. Are you breastfeeding?

6. Are you taking medication?

7. Are you taking birth control?

Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months

Please check Yes or No for each current or past condition

Yes No

Blood disorders:

(hemophilia, anemia, prolonged bleeding)

Heart conditions:

Infraction ( heart attack), angina, surgery, etc.
Heart infection (endocarditis)
Surgery to replace or repair a valve / cusp

Blood pressure

Blood disorders:

Dizziness, faiting

Frequent headaches

Jaw pain

Liver disorder (hepatitis A, B, C. cirrhosis, etc.)

Digestive system disorders or diseases

Stomach disorders

Kidney disorders

Diabetes

Thyroid disorders

Cancer(tumour) Specify:

Radiotherapy
Chemotherapy

Do you suffer from dry mouth?

Sexually transmitted or blood-borne infections (STBBI)


Yes No

Skin diseases

Eye disorders

Earaches

Arthritis

Osteoporosis:

Prevention / treatment (e.g.: tablets)
Annual or monthly injection

Chronic pain

Epilepsy

Nervous system disorders or diseases

Mental disorders or illnesses

Frequent colds or sinusitis

Tuberculosis or lung disorders

Asthma

Hay fever / seasonal allergies

Allergy or manifestation with products containing:

Latex

Penicillin

Other antibiotics

Codeine

Aspirin

Sulfonamides

Anesthetic

Food

Iodine-containing
products

Other

Other aspects

Yes No

Do you snore?

Do you suffer from sleep apnea?

Do you smoke?

Do you drink alcohol?

Do you take drugs?

Do you take methadone?

Consent to communicate with a health professional

Family physician, specialist, pharmacist, other

I hereby agree to allow the dentist and his or her staff to obtain information that is relevant to or consistent with the purpose of the file from the health professionals listed above or to disclose such information to these health professionals.

Consent and identification

I have filled out this medical-dental questionnaire to the best of my knowledge.

I hereby consent and state my authorization to have my dentist and other staff at Centre Dentaire Familial communicate with me by email or standard SMS messaging and/or iMessage regarding various aspects of my dental care, which may include, but shall not be limited to, follow-ups, prescriptions, appointments, and billing. I understand that email and standard SMS messaging and/or iMessage are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging and/or iMessage regarding my dental care might be intercepted and read by a third party.

Patient him/herself

Parent/guardian (if under 14 yrs. old)

Legal/authorized representative

Other