Medical Form

Last name *

First name *

Date of birth *

Provincial health insurance no

Expiration

Address *

City *

App.

Postal code *

Phone - home

Phone - work

Phone - cellular

Referred by

Person in charge (if patient is minor)

RoleFatherMotherGuardianOther

Email *

Occupation

Dental insuranceyesno

Company

Policy Num.

Certificate Num.

Name of insured

Date of birth (of insured)

Medical History

Are you currently under the care of a physician ? yesno

Name of your doctor : 

Speciality :

Frequency of follow-ups :

Reason :

Have you been hospitalized in the past 2 years? yesno

Reason :

Year :

Reason :

Year :

Reason :

Year :

Do you use Tobacco, Vaper, Drug, Alcohol ?yesno

Specify:

Frequency of use :

Woman

Are you pregnant?yesno

how many weeks

Do you take birth control pills?yesno

Are you menopausal ?yesno

Do you suffer or have you suffered from :

Cardiac disorders (Infarction, Angina, Arrhythmia, Heart murmur, Endocarditis, Valve disease)yesno

Blood pressure disorders (High or Low)yesno

Vascular disorders (ACV, Thrombophlebitis)yesno

Blood disorders (Hemophilia, Anemia, Mononucleosis)yesno

Pulmonary disorders (Asthma, Emphysema, Tuberculosis, COPD)yesno

Liver Disorders (Jaundice, Hepatitis A, B, C, Cirrhosis)yesno

Digestive disorders (gastric reflux, stomach ulcer, Crohn's disease)yesno

Thyroid Disorders : (Hypothyroidism / Hyperthyroidism)yesno

Kidney Disorders (Kidney Failure, Kidney Stone)yesno

Neurological disorders (epilepsy, Parkinson's)yesno

Multiple sclerosis ?yesno

Cognitive and learning disorders (HAT, ADHD, Autism, PDD)yesno

Psychiatric disorders (Depression, Anxiety, Schizophrenia, bipolarity)yesno

Inflammatory diseases (Arthritis, Rheumatoid Arthritis)yesno

Osteoporosis ?yesno

Prevention/treatment (by tablets) ?yesno

Annual or monthly injection ?yesno

Infections transmitted by blood and saliva (STBBIs/STDs)yesno

Specify the infection :

Are you HIV positive ?yesno

Rheumatic Feveryesno

Diabetes (Type I or Type II)noType IType II

Sinusitis, chronic rhinitisyesno

Eye problem (Glaucoma)yesno

Cancer (tumor)yesno

Year

Treatments : (Chemotherapy/Radiotherapy) ?

Have you ever had a transplant ?yesno

Transplant year

Transplant location

Do you have one or more joint prostheses ? (Hip, knee) yesno

For how many years

Do you follow a special diet ?yesno

Do you have Acquired Immune Deficiency Syndromeyesno

Do you have frequent headaches, migraines, Earachesyesno

Loss of consciousness, dizziness yesno

Snoring or sleep apneayesno

Do you have a CPAP ? yesno

Abnormal weight loss or gain, Anorexia, difficulty swallowingyesno

Significant fatigue or stressyesno

Skin problem (Psoriasis, Eczema, Other)yesno

Hay fever / Seasonal allergiesyesno

Do you suffer from dry mouth ?yesno

Do you take or have you ever taken bisphosphates to treat an illness ?yesno

Do you take medication, natural or homeopathic products ? yesno

medication, natural or homeopathic infos

Drug name

Mg/day

Disease treated

Drug name

Mg/day

Disease treated

Drug name

Mg/day

Disease treated

Have you ever had an allergic reaction to the following products :

Latexyesno

Aspirin / Ibuprofen / Acetaminophenyesno

Penicillinyesno

Sulfonamidesyesno

Codeineyesno

Iodineyesno

Local anesthesiayesno

Foodyesno

Others

I, undersigned, declare having read, understood, and informed myself and have responded to the best of my knowledge to the medical questionnaire. I hereby take the responsibility to advise you of any change in my health.
Patient initials:

I agree to contact Centre Dentaire Griffin at least 48 hours before appointment time if my appointment has to be changed. (This time is reserved for you. Fees of 60$ for each hour missed will be applied to your account for non-compliance with this policy.).
Patient initials: