CONFIDENTIAL MEDICAL-DENTAL QUESTIONNAIRE

A patient’s dental file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office, where only the dentist and his or her staff have access to it. Patients are also entitled to access their file and make corrections.

This questionnaire will help the dentist and his or her staff provide the best possible care and reduce the risk of medical complications. It is in the patient’s best interest to carefully fill it out and notify the dentist of any change in their health condition.

Name*

First nameLast name

Sex*

FemaleMaleOther

Date of birth*

Date

Health Insurance

NumberExpiry date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Name of emergency contact*

First NameLast Name

Relationship to patient

Phone Number*

Please enter a valid phone number.

Reason for dental visit*

Do you fear dental treatments?

Not at allVery littleVery much

Specify:

Last visit:*

0 - 6 months6 - 12 monthsMore than 12+ months

Treatment(s) received:

	Yes	No
With panoramic radiographs (large x-ray)
With intraoral radiographs (small x-rays)

	Yes	No
Would you like to speak privately with your dentist?
Are you being treated by a physician?
Have you ever had surgery or been hospitalized?
Do you have joint prostheses (hip, knee, etc.)?
Have you gained or lost a lot of weight recently?

If answered yes above, please state the name of your physician

Name and phone number of your pharmacy

	Yes	No
Are you pregnant?
Are you breastfeeding?
Are you taking natural or homeopathic products?
Are you taking medication?
Are you taking birth control?
Are you taking birth hormones?

Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months

Please check Yes or No for each current or past condition*

	Yes	No
Blood disorders (hemophilia, anemia, prolonged bleeding)
Heart conditions Infarction (heart attack), angina, surgery, etc
Heart infection (endocarditis) Surgery to replace or repair a valve /cusp
High blood pressure
Low blood pressure
Dizziness, fainting
Frequent headaches
Jaw pain
Liver disorders (hepatitis A, B, C. cirrhosis, etc.)
Digestive system disorders or diseases (if yes, specify in notes below)
Stomach disorders (ulcer or reflux)
Kidney disorders
Diabetes
Thyroid disorders
Cancer (tumour) (If yes, specify below)
Radiotherapy
Chemotherapy
Do you suffer from dry mouth?
Sexually transmitted or blood-borne infections (STBBI) (If yes, specify below)
Skin diseases
Eye disorders
Earaches
Arthritis
Osteoporosis Prevention / treatment (e.g.: tablets)
Osteoporosis Annual or monthly injection
Chronic pain
Epilepsy
Nervous system disorders or diseases
Mental disorders or illnesses
Frequent colds or sinusitis
Tuberculosis or lung disorders
Asthma
Hay fever / seasonal allergies

Specify

Allergy or manifestation with products containing: *

	Yes	No
Latex
Penicillin
Other antibiotics
Codeine
Aspirin
Sulfonamides
Anesthetic
Food
Iodine-containing products
Other (if yes, mention below)

Other allergies,

Do you have other medical conditions that should be mentioned?

Other aspects

	Yes	No
Do you snore?
Do you suffer from sleep apnea?
Do you take drugs?
Do you take methadone?

Do you smoke?

YesNoEx smoker

If yes, how many cig./day

Do you drink Alcohol?

NoYes

If yes, how frequently? number per day/week/month

	Yes	No
Does your jaw click or hurt?
Do you feel you grind your teeth?
Have you ever had orthodontic treatment?
Do you wear a night guard?
Have you ever had gum disease?
Do you bite your lips or cheek often?
Do you think you have occasional bad breath?
Do your gums ever bleed when you brush your teeth?
Do you experience sensitivity with hot/cold?
Does floss ever tear between your teeth?
Does food get jammed between your teeth?
Do your teeth ever hurt when you bite hard?

I the undersigned, hereby declare that I have read, understood, and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health.
I authorize the setting up of my dental file, the follow-up, as well as my registration on the recall list(s) of the treating dentist(s).

I have been informed that my file will be kept in the office at all times and that only the dentist(s) and his/her (their) auxiliary personnel will have access to it.

I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.

YesNo

Patient Signature*

Doctor's Signature

CONFIDENTIAL MEDICAL-DENTAL QUESTIONNAIRE

Personal Information

Dental Information

Medical History

Dental History