Questionnaire Médical | Clinique Dentaire Richard Landry

MEDICAL QUESTIONNAIRE

To be completed before your first visit
Section 1. General information
Patient's name*

First nameLast name
Date of birth*

DayMonthYear
FM
Private insurance company
Insurance policy number
Certificate
Home tel.:*
Work tel.:
Ext.:
Cell phone:
Address*

Street Address Line 2

Country
Email
Occupation
Employer
Reason for consultation
Section 2. References
Recommendation of a friend or family memberPassing through the neighborhoodInternet/GoogleInstagramFacebookAutre
Section 3. Medical information

Check Yes or No for each current or past condition:*

Rows	Yes	No
Cancer
Asthma
Diabetes
Neurological disease
Hearth conditions
Pulmonary Disease
Epilepsy
Psychiatric illness
Cold sores
Hepatitis B
Hepatitis C
HIV (AIDS virus)
Sleep Apnea
Blood disorders
Anemia
Blood pressure (high or low)
Digestive system disorders or diseases
Earaches
Thyroid disorder
Frequent headaches
Dizziness, fainting
Current drug(s):
Other medical history(s):

Allergies:*

Consumption:*

Rows	Frequency
Alcohol
Smoking (cigarette or vapoting)
Marijuana
Drugs? If yes, please specify:

Dental treatments:*

Covid-19:*

Rows	Yes	No
Fever
Sore throat
Cough
Loss of smell
Loss of taste
Breathing difficulties
Have you had Covid-19 (test +)
Hospitalization
Contact with an infected person

I have filled out this medical-dental questionnaire to the best of my knowledge.
Signature:*

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Date

DayMonthYear
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MEDICAL QUESTIONNAIRE