Contact

Tran & Tran Cabinet Dentaire
154 Avenue Laurier Ouest #230
Montréal, QC
H2T 2N7
t. :514-729-1869

Horaires

Lun : 8h30 à 17h.

Mar : 9h00 à 19h.

Mer : 8:30 à 17h.

Jeu : 8h30 à 17h.

Ven : 8h30 à 16h.

Sam et dim : Fermés

Soyez informé


CONFIDENTIAL QUESTIONNAIRE OF INTRODUCTION

 

 

Version française

Personal information

Gender :*
First name :*
Last name :*
Address :
City :
Province :
Postal code :
Home telephone :*
Work telephone :*
Ext :
Email :* Birth date :
Month :
Year:
If child, parent's name :
Medicare card No :
Expiry :
Year :
In case of emergency :
Referred by :
Motive for visit :

Medical History

Weight :
Height :
1- Are you currently under the care of a physician? :
If yes, provide his/her name :
Physician's Tel :
Ext :
2- Are you currently taking or have you taken any medication in the last six months?
If yes, please describe them below:
3-Did you experience a significant weight loss or gain lately?
4-Are you pregnant?
5-Are you taking a hormonal contraceptive?

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

7-Heart disease (infarction, angina, valve problems, shortness of breath)?
8-Rheumatic fever?
9-Prolonged bleeding?
10-Anemia?
11-Blood pressure?
12-Frequent colds or sinusitis?
13-Tuberculosis or lung problems?
14-Digestive problems?
15-Stomach ulcers?
16-Liver problems (hepatitis A, B, C or cirrhosis)?
17-Kidney problems?
18-Sexually transmitted infections (STIs)?
19-Diabetes?
20-Thyroid problems?
21-Skin disease?
22-Vision problems?
23-Arthritis?
24-Epilepsy?
25-Nerve problems?
26-Frequent headaches?
27-Dizziness, fainting?
28-Earaches?
29-Hay fever?
30-Asthma?
31-Do you smoke?
32-Have you ever had radiation treatments or chemotherapy?
33-Do you have acquired immunodeficiency syndrome (AIDS)?
34-Have you tested positive for AIDS?
35-Do you have any joint prostheses?

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

Foods
Penicillin
Aspirin
Iodine
Sulpha drugs
Codeine
Local anesthetic
Others:
Explain:
36- Have you ever been hospitalized or undergone surgery, other than dental surgery?
If yes, specify the type of surgery and when:
37-Do you wish to discuss your health with the dentist?
FOR THE PHYSICIAN'S USE ONLY
Precautions:

Dental History

Date of last dental visit:
Treatment received

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

1-Oral hygiene demonstration?
2-Gum treatment?
3-Orthodontic treatment (braces)?
4-Root canal treatment?
5-Fillings?
6-Crown(s) or bridge(s)?
7-Full or partial prostheses?
8-Dental surgery or extraction?
9-Dental implants?
10-Dental x-rays?
11-Others?
patient : _________________________________________________ date _________ dentiste : _________________________________________________ date _________ By submitting this electronic form, I, the undersigned, hereby declare that I have read, understood and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of the attending dentist(s). I have been informed that my file will be kept in the office at all times and that only the dentist(s) and his/her (their) auxiliary personnel will have access to it I have also been informed of my right to consult my file,to request that it be corrected, if necessary, and to remove my name from the recall list. I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be. The sending of this electronic form serves as signature. Produced by the Association des Chirurgiens dentistes du Québec in collaboration with the Ordre des dentistes du Québec. All rights reserved.