3845 Rue Jean-Talon O, Montreal, QC, H3R 2G4
514-731-3269
Clinic
About
Clinic Gallery
Team
New Patients
Medical Form
Emergency Care
Services
Smile Gallery
Contact
FR
Clinic
About
Clinic Gallery
Team
New Patients
Medical Form
Emergency Care
Services
Smile Gallery
Contact
FR
Medical Form
Medical Form
Basic Information
Name
*
First
Last
Sex
*
Male
Female
Address
*
Street Address
Address Line 2
City
Postal Code
Home Phone
*
Work Phone
Email
*
Date of Birth
*
DD dash MM dash YYYY
In an emergency, contact:
*
Name of your dentist
Person who referred you
Reason for your visit
Medical History
Are you currently followed by a doctor?
Yes
No
Name of doctor, and phone number:
Do you currently take medication or in the last six months?
Yes
No
Please list all medications:
*
Are you pregnant?
Yes
No
Have you ever suffered or are you suffering from...
Cardiac disorders (myocardial infarction, angina, valve problems, breathing problems)?
Yes
No
Rheumatic fever?
Yes
No
Prolonged bleeding?
Yes
No
Anemia ?
Yes
No
Blood pressure?
Yes
No
Frequent colds or sinusitis?
Yes
No
Tuberculosis or lung problems?
Yes
No
Stomach problems, digestive disorders?
Yes
No
Liver problems (hepatitis A, B, C, cirrhosis)?
Yes
No
Kidney problems?
Yes
No
Diabetes?
Yes
No
Thyroid problems?
Yes
No
Skin diseases?
Yes
No
Eye Problems?
Yes
No
Arthritis?
Yes
No
Epilepsy?
Yes
No
Frequent headaches?
Yes
No
Dizziness, fainting?
Yes
No
Earache?
Yes
No
Asthma?
Yes
No
Sleep apnea?
Yes
No
Are you a smoker?
Yes
No
Have you ever had radiation treatment or chemotherapy?
Yes
No
Do you have artificial joints?
Yes
No
Do you have any allergies to food or medications?
Yes
No
Please specify your allergies:
*
Do you have an allergy to latex or any metal?
Yes
No
Have you ever been hospitalized or undergone surgery other than dental?
Yes
No
Which hospital and when?
*
Comments
Dental History
Last dental visit
*
0-6 months
6-12 months
12+ months
Treatments received
Do you have pain in the mouth or joints?
Yes
No
Have any permanent teeth been removed?
Yes
No
Have any permanent teeth been injured or chipped by an accident?
Yes
No
Do you have any head or face injuries?
Yes
No
Do you have any speech problems?
Yes
No
Have you ever sucked a thumb or fingers?
Yes
No
Until what age?
*
Do you breathe predominantly by the mouth?
Yes
No
Do you have tongue thrust?
Yes
No
Do you grind or clench teeth?
Yes
No
Do you play a wind instrument?
Yes
No
Have you seen another orthodontist?
Yes
No
Do you have any recent radiographs? (x-rays)
Yes
No
Do you have any clicking, cracking or pain in jaw?
Yes
No
Have you ever had the following dental treatment or services...
Demonstration of oral hygiene?
Yes
No
Gum treatment?
Yes
No
Orthodontic treatment (braces)?
Yes
No
Root canal?
Yes
No
Dental surgery or extraction?
Yes
No
Dental implants?
Yes
No
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