First visit form

You must first fill out a form collecting details about your health before your first appointment at the clinic. To expedite the process , please fill out the form below.

Please, note that all questions with a * are required.

In case of appointment cancellation, please notify us by telephone or email at least 48 hours in advance, otherwise you will pay a service fee.

Confidential Questionnaire of introduction

Situation*
MarriedSingleOther

Last name*

First name*

Sex*
FM

Birthdate*

Address*

City*

Postal code*

Phone at home
-

Phone at work
- #

Cellular
-

Email

Referred person email

Social insurance No.*

Expiry date*

If you are less than 18 years old, indicate name of parent, or guardian
ParentGuardian

For an emergency, contact*

Motive for visit

Referred by

Medical History

Weight*

Height*

Are you presently under a doctor’s care?*
YesNo

If so, reason

Doctor's name

Doctor's phone number
-

Are you presently taking any drug or medication, or have you taken any in the last six month?*
YesNo

If so, which

Are you presently taking natural or homeopathic products?*
YesNo

Specify

Birth control pills?*
YesNo

Hormones?*
YesNo

Specify

Did you recently experience a significant weight loss or gain?*
YesNo

Are you pregnant?*
YesNo

Are you breastfeeding?*
YesNo

Are you suffering or have you ever suffered from

Heart disease (stroke, angina, valvular problems, murmur)*
YesNo

Rheumativ fever*
YesNo

Hemophilia*
YesNo

Prolonged bleeding*
YesNo

Clear blood*
YesNo

Anemia*
YesNo

Others blood problems?

Blood pressure*
NormalLowHigh

Frequent colds or sinusitis*
YesNo

Tuberculosis or lung problems*
YesNo

Digestive problems*
YesNo

Specify

Stomach ulcer*
YesNo

Liver disease (hepatitis A,B,C, cirrhosis, etc.)*
YesNo

Kidney problems*
YesNo

Do you urinate often?*
YesNo

Venereal disease (V.D.)*
YesNo

Diabetes*
YesNo

Thyroid problems*
YesNo

Skin disease*
YesNo

Eye problems*
YesNo

Arthitis*
YesNo

Osteoporosis*
YesNo

Do you take bisphosphonates?*
YesNo

Epilepsy*
YesNo

Nervous disorders*
YesNo

Mental illness*
YesNo

Specify

Frequent headaches*
YesNo

Dizzy spells or fainting spells*
YesNo

Earaches*
YesNo

Hay fever*
YesNo

Asthma*
YesNo

Do you smoke?*
YesNooccasionally

Have you ever had radiotherapy or/and chemotherapy treatments (tumors)?*
YesNo

Do you have AIDS symptoms?*
YesNo

Are you an virus carrier?*
YesNo

Do you have artificial joints (knee, hip, etc.)?*
YesNo

Do you snore or have you ever been told that you snore?*
YesNo

Do you have any of the following allergies

Food*
YesNo

Latex*
YesNo

Penicillin*
YesNo

Aspirin*
YesNo

Lodine*
YesNo

Sulfonamides*
YesNo

Codeine*
YesNo

Local anaesthesia*
YesNo

Other antibiothics*
YesNo

Others, specify

Do you use drugs?*
YesNo

Do you drink alcohol?*
No/ A littleIn moderationA lot

Were you ever hospitalized or have undergone surgery other than dental?*
YesNo

If so, why and when?

Do you fear dental treatments?*
YesNo

Is there anything concerning your health you wish to discuss privately with your dentist?*
YesNo

Remarks

Dental History

Last visit*
0-6 months6-12 months24months +

Treatments received

Have you previously had dental treatments such as

Oral hygiene instructions*
YesNo

Gum treatment*
YesNo

Orthodontic treatment*
YesNo

Root canal treatment*
YesNo

Dental fillings*
YesNo

Crown or/and bridge*
YesNo

Partial or/and complete denture*
YesNo

Surgical treatment or extraction*
YesNo

Dental implants*
YesNo

X-rays*
YesNo

Others*
YesNo

If you had to choose among these four (4) choice , which would you choose?*
LongevityAestheticFunction (the act of chewing well)Comfort (without pain)

When you plan to undergo treatment , which aspects are obstacles for you?*
FearWaryTimeBudgetNo notion of urgency

In the professional use

FOR THE DENTIST

I have read the answers to the registration questionnaire and taking the usual measures, where appropriate.

Signature

I, the undersigned, have read, understood, and informed myself answering the medical questionnaire to the best of my knowledge. I hereby undertake to advise you of any change in my health. I authorize the constitution of my dental record, monitoring, and my registration on the recall list of dentists and contractors. I was informed that my file will be kept at the office at all times and that dentists and their support staff will have one access. I was also informed of my right to see my file, to request a correction and will retire from the recall list.

Signature