www.msmiline.com - Medical Form

Medical Form
Patient Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
RAMQ Number
Are you under a doctor's care*

YesNo
Do you or have you suffered from
Heart Ailments*

YesNo
High / Low Blood Pressure*

YesNo
Anemia*

YesNo
Diabetes*

YesNo
Kidney Problems*

YesNo
Aids*

YesNo
Arthritis*

YesNo
Nervous Complaints*

YesNo
Digestive Problems*

YesNo
Stomach Ulcer*

YesNo
Frequent Headaches*

YesNo
Ear Infections*

YesNo
Rheumatic Fever*

YesNo
Asthma*

YesNo
Tuberculosis, Lung Ailments*

YesNo
Liver Problems, Hepatitis, Cirrho*

YesNo
Venereal Disease*

YesNo
Eye Trouble*

YesNo
Epilepsy*

YesNo
Thyroid Trouble*

YesNo
Prolonged Bleeding*

YesNo
Do you have artificial joints?*

YesNo
Loss of consciousness*

YesNo
Do you suffer from allergies
Hay Fever*

YesNo
Aspirin*

YesNo
Local Anesthetics*

YesNo
Penicillin*

YesNo
Sulfamides*

YesNo
Other Antibiotics*

YesNo
If "Other Antibiotics" Please Explain*
Other Allergies*

YesNo
If "Other Allergies" Please Explain*
Are you Pregnant*

YesNo
Are you scared of dental treatments*

YesNo
Are you pleased with your smile?*

YesNo
What would you like to change?*
Do you take birth control pill, contraceptive?*

YesNo
Do you take medication?*

YesNo
List of present medication*
Are you a smoker?*

YesNo
Have you received radiotherapeutic treatments?*

YesNo
Surgery Name
Surgery Date

MonthDayYear
Date
Dental History
When was your last dental appointment?

MonthDayYear
Date
Have you had
Teeth extraction / oral surgeryDental X-raysGum TreatmentsHemorrhagingOrthodontic treatmentsRoot canal work
Do you have
Pain / Difficulty when opening your mouth?Bleeding of gumsUnreplaced missing teethLoose teeth
Do you snore?

YesNo
Referral
Referred By
Reason for visit
Payments
SelfInsuranceRAMQOther
Insurance Company
Policy Number
Identification Number
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: