Medical Form
Patient Full Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2015
2014
2013
2012
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2010
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2007
2006
2005
2004
2003
2002
2001
2000
1999
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Please Select
Male
Female
RAMQ Number
Are you under a doctor's care
*
Yes
No
Do you or have you suffered from
Heart Ailments
*
Yes
No
High / Low Blood Pressure
*
Yes
No
Anemia
*
Yes
No
Diabetes
*
Yes
No
Kidney Problems
*
Yes
No
Aids
*
Yes
No
Arthritis
*
Yes
No
Nervous Complaints
*
Yes
No
Digestive Problems
*
Yes
No
Stomach Ulcer
*
Yes
No
Frequent Headaches
*
Yes
No
Ear Infections
*
Yes
No
Rheumatic Fever
*
Yes
No
Asthma
*
Yes
No
Tuberculosis, Lung Ailments
*
Yes
No
Liver Problems, Hepatitis, Cirrho
*
Yes
No
Venereal Disease
*
Yes
No
Eye Trouble
*
Yes
No
Epilepsy
*
Yes
No
Thyroid Trouble
*
Yes
No
Prolonged Bleeding
*
Yes
No
Do you have artificial joints?
*
Yes
No
Loss of consciousness
*
Yes
No
Do you suffer from allergies
Hay Fever
*
Yes
No
Aspirin
*
Yes
No
Local Anesthetics
*
Yes
No
Penicillin
*
Yes
No
Sulfamides
*
Yes
No
Other Antibiotics
*
Yes
No
If "Other Antibiotics" Please Explain
*
Other Allergies
*
Yes
No
If "Other Allergies" Please Explain
*
Are you Pregnant
*
Yes
No
Are you scared of dental treatments
*
Yes
No
Are you pleased with your smile?
*
Yes
No
What would you like to change?
*
Do you take birth control pill, contraceptive?
*
Yes
No
Do you take medication?
*
Yes
No
List of present medication
*
Are you a smoker?
*
Yes
No
Have you received radiotherapeutic treatments?
*
Yes
No
Surgery Name
Surgery Date
-
Month
-
Day
Year
Date
Dental History
When was your last dental appointment?
-
Month
-
Day
Year
Date
Have you had
Teeth extraction / oral surgery
Dental X-rays
Gum Treatments
Hemorrhaging
Orthodontic treatments
Root canal work
Do you have
Pain / Difficulty when opening your mouth?
Bleeding of gums
Unreplaced missing teeth
Loose teeth
Do you snore?
Yes
No
Referral
Referred By
Reason for visit
Payments
Self
Insurance
RAMQ
Other
Insurance Company
Policy Number
Identification Number
Patient Signature
*
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: