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First name
Family Name
Date of birth (dd/mm/yyyy)
Health card number
Expiry
Address
City
Province
Postal code
Home telephone
Cell phone
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Emergency Contact Name
Relationship to patient
Emergency contact's telephone number
Reason for today's visit
Do you fear dental treatments (not at all/a little/very much) Pas du toutUn peuBeaucoup
Specify your fears
Last visit 0-6 mois6-12 mois+ de 12 mois
Treatment received
With panoramic radiographs (large x-ray) OuiNon
With intraoral radiographs (small x-rays) Oui 2Non 2
Would you like to speak privately with your dentist? Oui 3Non 3
Are you being treated by a physician? Oui 4Non 4
Have you ever had surgery or been hospitalized? Oui 5Non 5
Do you have joint prostheses (hip, knee, etc.)? Oui 6Non 6
Have you gained or lost a lot of weight recently? Oui 7Non 7
Are you pregnant? Oui 8Non 8
Are you breastfeeding? Oui 9Non 9
Are you taking natural or homeopathic products? Oui 10Non 10
Specify Products
Are you taking medication? Oui 11Non 11
Are you taking birth control or hormones? Oui 12Non 12
Medication and reason
Blood disorders (hemophilia, anemia, prolonged bleeding) Oui 13Non 13
Infarction (heart attack), angina, surgery, etc. Oui 14Non 14
Heart infection (endocarditis) Oui 15Non 15
Surgery to replace or repair a valve /cusp Oui 16Non 16
High or Low Blood pressure Oui 17Non 17
Dizziness, fainting Oui 18Non 18
Frequent headaches Oui 19Non 19
Jaw pain Oui 20Non 20
Liver disorders (hepatitis A, B, C. cirrhosis, etc.) Oui 22Non 22
Digestive system disorders or diseases Oui 23Non 23
Specify digestive issues
Stomach disorders Oui 24Non 24
Kidney disorders Oui 25Non 25
Diabetes Oui 26Non 26
Thyroid disorders Oui 27Non 27
Cancer (tumour) Oui 28Non 28
Specify type of cancer if applicable
Have you ever had radiotherapy? Oui 29Non 29
Have you ever had chemotherapy? Oui 30Non 30
Do you suffer from dry mouth? Oui 31Non 31
Have you had or do you have any sexually transmitted or blood-borne infections (STBBI)? Oui 32Non 32
If yes, specify:
Do you snore? Oui 33Non 33
Do you suffer from sleep apnea? Oui 34Non 34
Do you smoke? Oui 35Non 35
If yes, indicate number cigarettes per day
Please select this box if you are an ex-smoker Ex-smoker
Do you consume alcohol Oui 36Non 36
Is it on a regular basis? Oui 37Non 37
If yes, Indicate the number of drinks
If yes, frequency (per day/per week/per month) joursemainemois
Do you take drugs? Oui 38Non 38
Do you take methadone? Oui 39Non 39
Skin diseases Oui 40Non 40
Eye disorders Oui 41Non 41
Earaches Oui 42Non 42
Arthritis Oui 43Non 43
Osteoporosis Oui 44Non 44
Osteoporosis prevention/treatment (e.g.tablets) Oui 45Non 45
Osteoporosis annual or monthly injection Oui 46Non 46
Chronic pain Oui 47Non 47
Epilepsy Oui 48Non 48
Nervous system disorders or diseases Oui 49Non 49
Mental disorders or illnesses Oui 50Non 50
Frequent colds or sinusitis Oui 51Non 51
Tuberculosis or lung disorders Oui 52Non 52
Asthma Oui 53Non 53
Hay fever/seasonal allergies Oui 54Non 54
Latex Oui 55Non 55
Penicillin Oui 56Non 56
Other antibiotics Oui 57Non 57
Codeine Oui 58Non 58
Aspirin Oui 59Non 59
Sulfonamides Oui 60Non 60
Anesthetic Oui 61Non 61
Food Oui 62Non 62
Iodine-containing products Oui 63Non 63
Other Oui 64Non 64
Please list any other medical conditions that should be mentioned
Insurance Company Name (if applicable)
Insurance Policy Number (if applicable)
Insurance Policy Subscriber ID (if applicable)
Date (dd/mm/yyyy)
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