New Patients

Medical Questionnaire

To help prepare for your visit, please complete this questionnaire to the best of your knowledge. This information helps us provide safe care tailored to your needs.

Before You Begin

Please allow a few minutes to complete the form. If your health condition changes, please let our team know at your next visit.

Please enable JavaScript in your browser to complete this form.

First Name *

Last Name *

Gender *

F
M
X

Date of Birth (DD/MM/YYYY) *

Health Insurance Number *

(For patients 10 years old and under)

Expiration *

(For patients 10 years old and under)

Address *

City *

Province *

Postal Code *

Home Phone *

Cell Phone

Email *

Name of Emergency Contact *

Relationship to Patient *

Emergency Contact Phone Number *

Reason for Visit *

Last Visit to the Dentist *

0 to 6 months
6 to 12 months
More than 12 months

Treatment(s) Received During Your Last Visit *

Have you had a panoramic dental X-ray? *

Yes
No

Have you had intraoral dental X-rays? *

Yes
No

Are you afraid of dental treatments? *

Not at all
A bit
A lot

If yes, or if you have any concerns, please specify. *

Would you like to speak privately with your dentist? *

Yes
No

Are you currently under the care of a physician? *

Yes
No

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Have you ever had surgery or been hospitalized? *

Yes
No

Do you have any joint prostheses, such as a hip or knee replacement? *

Yes
No

Have you recently gained or lost a significant amount of weight? *

Yes
No

Are you pregnant? *

Yes
No

Are you breastfeeding? *

Yes
No

Do you take any natural or homeopathic products? *

Yes
No

Do you take any medications? *

Yes
No

Do you take birth control pills or hormone therapy? *

Yes
No

Do you have any blood disorders, such as hemophilia, anemia, or prolonged bleeding? *

Yes
No

Please list all medications you are currently taking or have taken within the past 12 months, along with the reason for taking them. *

Reason, details, and date related to the previous answers. *

Have you ever had a heart infection, such as endocarditis? *

Yes
No

Have you had surgery to place or repair a heart valve? *

Yes
No

Do you have high blood pressure? *

Yes
No

Do you have low blood pressure? *

Yes
No

Do you experience dizziness or fainting? *

Yes
No

Do you experience frequent headaches? *

Yes
No

Do you have pain in your jaw joint? *

Yes
No

Do you have any liver problems, such as hepatitis or cirrhosis? *

Yes
No

Do you have any digestive system disorders or diseases? *

Yes
No

If yes, please specify.

Do you have a stomach ulcer? *

Yes
No

Do you have acid reflux? *

Yes
No

Do you have any kidney problems? *

Yes
No

Do you have diabetes? *

Yes
No

Do you have any thyroid disorders? *

Yes
No

Do you have, or have you ever had, cancer or a tumor? *

Yes
No

If yes, please specify.

Have you received radiation therapy? *

Yes
No

Have you received chemotherapy? *

Yes
No

Souffrez-vous de sécheresse de la bouche? *

Yes
No

Do you have, or have you ever had, a sexually transmitted or blood-borne infection? *

Yes
No

If yes, please specify.

Do you have a skin condition? *

Yes
No

Do you have any eye problems? *

Yes
No

Do you have earaches? *

Yes
No

Do you suffer from arthritis? *

Yes
No

Do you suffer from osteoporosis? *

Yes
No

Are you taking any preventive treatment or medication for osteoporosis? *

Yes
No

Do you receive an annual or monthly injection for osteoporosis? *

Yes
No

Do you suffer from chronic pain? *

Yes
No

Do you suffer from epilepsy? *

Yes
No

Do you have any nervous system disorders or diseases? *

Yes
No

Do you have any psychiatric disorders or conditions? *

Yes
No

Do you frequently have colds or sinusitis? *

Yes
No

Do you have, or have you ever had, tuberculosis or any lung problems? *

Yes
No

Do you suffer from asthma? *

Yes
No

Do you suffer from hay fever or seasonal allergies? *

Yes
No

Do you have an allergy or reaction to any of the following products? *

Latex
Pénicilline
Other antibiotics
Codeine
Aspirin
Sulfonamides
Anesthetics
Foods
Products containing iodine
Other
None

If you selected “Other,” please specify.

Other medical conditions to mention

Have you ever been told that you snore or seem to stop breathing while you sleep? *

Yes
No

Do you wake up feeling tired in the morning or experience fatigue during the day? *

Yes
No

Do you suffer from sleep apnea? *

Yes
No

Do you smoke? *

Yes
No

If you smoke, how many cigarettes per day? *

Do you drink alcohol? *

Yes
No

If yes, how often do you drink alcohol?

Do you use cannabis? *

Yes
No

Do you use any other drugs? *

Yes
No

Do you take methadone? *

Yes
No

Confirmation *

I confirm that I have completed this medical-dental questionnaire to the best of my knowledge.

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