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Confidential Registration Form

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Confidential Registration Form

Confidential Registration Form

CONFIDENTIAL MEDICAL-DENTAL QUESTIONNAIRE

A patient’s dental 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 access their file and make corrections.

Personal Information

Name:*

First

Last

Sex:*

F

M

Other

Date of Birth :*

day

/

month

/

year

Health Ins. No. :

Expiry Date:

day

/

month

/

year

Address:*

Street Address City State / Province / Region Postal / Zip Code Country

Contact Information

Home tel. :*

Area Code

-

Phone Number

Work tel. :

Area Code

-

Phone Number

Cell phone :

Area Code

-

Phone Number

E-mail:

For emergencies, call:

Name of third person:

First

Last

Relationship to patient:

Main tel. :

Area Code

-

Phone Number

Cell. :

Area Code

-

Phone Number

Dental Information:

Reason for today's visit:

Select:

Specifiy:

Do you fear dental treatments?:

Not at all

A little

Very much

Specify:

Last visit :

0-6 months

6-12 months

+ 12 months

With panoramic radiographs (large x-ray) :

Yes

No

With intraoral radiographs (small x-rays) :

Yes

No

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.

Medical history:

Are you being treated by a physician? :*

Yes

No

Reason, details and date:(1)

Have you ever had surgery or been hospitalized? :*

Yes

No

Reason, details and date:(2)

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

Yes

No

Reason, details and date:(3)

Have you gained or lost a lot of weight recently? :*

Yes

No

Reason, details and date:(4)

Are you pregnant? :*

Yes

No

Are you breastfeeding? :*

Yes

No

Are you taking natural or homeopathic products? :*

Yes

No

Specify :

Are you taking medication? :*

Yes

No

Are you taking birth control, or hormones? :*

Birthcontrol

Hormones

No

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

Blood disorders(hemophilia, anemia, prolonged bleeding) :*

Yes

No

Heart conditions

Infarction (heart attack), angina, surgery, etc. :*

Yes

No

Heart infection (endocarditis) :*

Yes

No

Surgery to replace or repair a valve /cusp :*

Yes

No

Blood pressure:*

High

Low

No

Dizziness, fainting :*

Yes

No

Frequent headaches :*

Yes

No

Jaw pain :*

Yes

No

Liver disorders (hepatitis A, B, C. cirrhosis, etc.) :*

Yes

No

Digestive system disorders or diseases :*

Yes

No

Specify the diseases or the disorders:

Stomach disorder :*

Ulcer

Reflux

No

Kidney disorders :*

Yes

No

Diabetes :*

No

Type I

Type II

Thyroid disorders :*

Yes

No

Cancer (tumour) :*

Yes

No

Specify the cancer:

Chemotherapy :*

Yes

No

Sexually transmitted or blood-borne infections (STBBI) :*

Yes

No

Specify STBBI:

Skin diseases :*

Yes

No

Eye disorders :*

Yes

No

Earaches :*

Yes

No

Arthritis :*

Yes

No

Osteoporosis :*

Prevention / treatment (e.g.: tablets)

Annual or monthly injection

No

Chronic pain :*

Yes

No

Epilepsy :*

Yes

No

Nervous system disorders or diseases :*

Yes

No

Mental disorders or illnesses :*

Yes

No

Frequent colds or sinusitis :*

Yes

No

Tuberculosis or lung disorders :*

Yes

No

Asthma :*

Yes

No

Hay fever / seasonal allergies :*

Yes

No

Allergy or manifestation with products containing:

Latex :*

Yes

No

Penicillin :*

Yes

No

Other antibiotics :*

Yes

No

Which?

Codeine :*

Yes

No

Aspirin :*

Yes

No

Sulfonamides :*

Yes

No

Anesthetic :*

Yes

No

Food :*

Yes

No

Iodine-containing products :*

Yes

No

Other:

Other medical conditions that should be mentioned:

Other aspects:

Do you snore? :*

Yes

No

Do you suffer from sleep apnea? :*

Yes

No

Do you smoke? :*

Yes

No

How many cig./day?:

ex-smoker? :*

Yes

No

Do you drink alcohol? :*

Yes

No

Frequency :*

Day

Week

Month

Do you take drugs? :*

Yes

No

Do you take methadone? :*

Yes

No

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.

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.*

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

MELVILLE DENTAL GROUP

Clinique dentaire Westmount | Montréal

4484 Rue Sherbrooke Ouest,
Westmount, QC H3Z 1E6

Tel: (514) 379-4040
Mail: info@melvilledental.com

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