Parodontie Rockland

MEDICAL QUESTIONNAIRE

Use our SECURE online form to complete your health questionnaire. It’s simple, easy and quick! Our online medical questionnaire will allow the periodontist and its team to provide you treatments in a safe manner. It is simple, secure and fast! It is important to complete it thoroughly and to inform us of any changes in your health status.

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YOUR INFORMATIONS

First Name*

Last Name*

Birth Date*

Residential address*

City*

Province*

Postal Code*

Email*

Home phone*

Office Phone

Mobile

Do you have dental insurance?*

Yes

Employer

In case of emergency, contact (name)*

Relationship*

Phone*

Who referred you?

Dentist

MEDICAL HISTORY

Date of last medical examination

Family doctor*

1. Are you presently taking any medication or natural products*

Yes

If yes, specify

2. Have there been any other medications in the past year?*

Yes

If yes, specify

3. Are you allergic to certain medications?*

Yes

If yes, specify

4. Do you have any other allergies?*

Yes

If yes, specify

5. Have you ever had any unusual reactions to (please check):?

Local anesthesia

Yes

If yes, specify

Penicillin

Yes

If yes, specify

Iodine

Yes

If yes, specify

Sulfonamide (sulfa)

Yes

If yes, specify

Other medications

Yes

If yes, specify

6. Please check YES or NO to each of the current or past conditions:

Are you followed by a doctor?

Are you followed by a doctor?*

Yes

Skin disease

Skin disease*

Yes

Were you ever hospitalized?

Were you ever hospitalized?*

Yes

Eye problems

Eye problems*

Yes

Blood problems (hemophilia, anemia, prolonged bleeding)

Blood problems (hemophilia, anemia, prolonged bleeding)*

Yes

Earaches

Earaches*

Yes

Heart disease (heart attack, angina, valvular disease, murmur)

Heart disease (heart attack, angina, valvular disease, murmur)*

Yes

Heart infection (endocarditis)

Heart infection (endocarditis)*

Yes

Replacement of heart valves / stent

Replacement of heart valves / stent*

Yes

Osteoporosis - Prevention/treatment (tablet)

Osteoporosis - Prevention/treatment (tablet)*

Yes

Osteoporosis - Annual or monthly injection

Osteoporosis - Annual or monthly injection*

Yes

Chronic Pain

Chronic Pain*

Yes

Blood pressure

Blood pressure*

High

Low

Cholesterol

Cholesterol*

Yes

Stroke (CVA)

Stroke (CVA)*

Yes

Epilepsy

Epilepsy*

Yes

Nervous system disorders/diseases

Nervous system disorders/diseases*

Yes

Psychiatric Disorders/Diseases

Troubles / maladies psychiatriques*

Yes

Dizziness, fainting

Dizziness, fainting*

Yes

Frequent colds or sinusitis

Frequent colds or sinusitis*

Yes

Frequent headaches

Frequent headaches*

Yes

Tuberculosis / lung problems

Tuberculosis / lung problems*

Yes

Liver problem (hepatitis A, B, C, cirrhosis, etc.)

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

Yes

Asthma

Asthma*

Yes

Disorders or diseases of the digestive system

Disorders or diseases of the digestive system*

Yes

Hay fever / seasonal allergies

Hay fever / seasonal allergies*

Yes

Stomach problems (Ulcer or reflux)

Stomach problems (Ulcer or reflux)*

Yes

Cancer (tumor)

Cancer (tumor)*

Yes

Radiotherapy

Radiotherapy*

Yes

Chemotherapy

Chemotherapy*

Yes

Kidney disorders or diseases

Kidney disorders or diseases*

Yes

Diabetes (Type 1 or 2)

Diabetes (Type 1 or 2)*

Yes

Thyroid disorders (Hyper or hypo)

Thyroid disorders (Hyper or hypo)*

Yes

Anxiety

Anxiety*

Yes

Joint replacement (knee/hip)

Joint replacement (knee/hip)*

Yes

Organ transplant / medical implant

Organ transplant / medical implant*

Yes

Sexually transmitted and blood-borne infections (STBBIs)

Sexually transmitted and blood-borne infections (STBBIs)*

Yes

Are you HIV positive?

Are you HIV positive?*

Yes

Substance abuse

Substance abuse*

Yes

Do you use drugs

Do you use drugs*

Yes

Is there an illness, physical condition or problem that is not listed above that we should know about?*

Yes

If yes, specify

Do you smoke?*

Yes - Cigarette

Yes - Cannabis

Yes - Vaping

If yes, cig./day and nb. year

Do you drinking alcohol?*

Yes

Frequency

Woman only

Are you pregnant?*

Yes

Are you breastfeeding?*

Yes

Birth control pill?*

Yes

DENTAL HISTORY

1. Please check YES or NO to each of the questions:

Do your gums bleed?

Do your gums bleed?*

Yes

Do you feel you have bad breath?

Do you feel you have bad breath?*

Yes

Do you grind or clench your teeth day or night?

Do you grind or clench your teeth day or night?*

Yes

Are your teeth sensitive?

Are your teeth sensitive?*

Yes

Do you have receding gums?

Do you have receding gums?*

Yes

Have you noticed a movement in your teeth?

Have you noticed a movement in your teeth?*

Yes

Do you feel that your teeth are mobile?

Do you feel that your teeth are mobile?*

Yes

Does food ever get heapped between your teeth?

Does food ever get heapped between your teeth?*

Yes

2. How often do you visit your dentist?

2. How often do you visit your dentist?*

3-4 month

6 month

9 month

12 month

irregularly

other

Last visit:

Reason for visit:

Last dental cleaning:

3. Have you ever had? (please check):

2. A quelle fréquence visitez-vous votre dentiste?*

Oral surgery

Periodontal treatment

Orthodontic treatment

Night guard

Other device

ACCEPTANCE

Patient or Guardian Signature*

Date

Réservé à l'administration

** RESERVED TO THE ADMINISTRATION**

Notes

Precautions

Specialist Signature

Specialist Name*

Date

Hidden

is Approval

Who is this for?