Patient / Prescriptions

CONFIDENTIAL INSCRIPTION FORM


Emergency


Medical background

1. Are you currently under the care of a doctor?
2. If you are taking or have taken medication in the past six months, specify:
Reason Drug name Name of doctor who prescribed it and telephone
Yes No
Yes No
3. Do you take natural or homeopathic products?
Anovulants [birth control pills]
Des hormones? Specifiez
4. Have you gained or lost a lot of weight lately?
5. Are you pregnant?
Are you breastfeeding?
Have you suffered or are you suffering from:
6. Heart problems
[infarction, angina, valve problems, breath]
7. Rheumatic fever
8. Blood problem :
8.1 Haemophilia
8.2 Prolonged bleeding
8.3 Clear blood
8.4 Anemia
8.5 Others, specify
9. Blood pressure [pressure]
High
Low
No
10. Frequent colds or sinusitis
11. Tuberculosis or lung problems
12. Digestive disorders
13. Stomach ulcer
14. Liver problems [hepatitis: virus A, B, C, cirrhosis, etc.]
15. Kidney problems
16. Urinate often?
17. Sexually Transmitted Infections [STIs]?
18. Diabetes?
19. Thyroid disorders?
20. Skin illness?
21. Eye problem [eyes]
22. Arthritis
23. Osteoporosis
Do you take bisphosphonates?
24. Epilepsie
25. Nervous disorder
26. Psychiatric illnesses
27. Frequent headaches
28. Dizziness, fainting
29. Earache
30. Hay fever
31. Asthma
32. Do you smoke?
33. Have you ever had radiation therapy and/or chemotherapy [tumor]?
34. Do you have aids?
35. Are you HIV positive?
36. Do you have joint prostheses? [hip, knee, etc,]?
37. Are you snoring or have you ever been told that you snore?
38. Have you ever had an allergic or other reaction to the following products?
38.1 Latex
38.6 Penicillin
38.2 Food
38.7 Codeine
38.3 Iodine
38.8 Other Antibiotics
38.4 Aspirin
38.9 Local anesthesia
38.5 Sulfonamides
38.10 Others
39. Do you use drugs?
40. Do you drink alcohol?
A lot
Moderate
Little or not
41. Do you fear dental treatments?
A lot
A little
Not at all
42. Have you ever been hospitalized or had any surgical procedures other than dental?
43. Would you like to discuss your health in private with your dentist?

Dental history

Last visit:
0-6 months
6-12 months
+ 12 months
Treatments received
Yes No
Yes No
Have you ever had dental treatments such as
1. Oral hygiene demonstration
2. Gum treatment
3. Orthodontic treatment
4. Tooth canal
5. Obturations
6. Crown(s) and/or bridges
7. Full and / or partial dentures
8. Oral surgery treatments or extractions
9. Dental implants
10. Dental x-rays
11. Other

To be completed by the client

I, the undersigned, declare that I have read, understood, inquired and answered the medical questionnaire to the best of my knowledge. I hereby undertake to notify you of any change in my state of health. I authorize the constitution of my dental file, its follow-up, as well as my inscription on the recall list of (the) dentiste(s) treating (s). I was also informed of my right to consult my file, to request a correction and to withdraw from the recall list.
Signature of patient or tutor
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