Confidential Health Questionnaire

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    Your privacy is very important to us. We are committed to earning your trust by safeguarding your personal information. All the information you provide to us is securely stored and is kept strictly confidential.

    IDENTIFICATION




    Please enter the date in this format: dd/mm/yyyy










    INSURANCE









    CONTACT



    TODAY'S VISIT


    Dentists provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your dentist provide you with the best possible care by informing him of these conditions.

    Please check the appropriate response

    HEALTH





    Do you have, or have you ever had:




    TREATMENT



    HOSPITALIZATION



    MEDICATION



    Are you allergic, or have you had any unusual reaction to any of the following?











    Do you have, or have you ever had, any of the following?




    WOMEN ONLY




    PAST AND CURRENT CONDITIONS


    DENTAL HISTORY



    Have you previously had dental treatments such as:












    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 of the attending dentist(s). 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.