CONFIDENTIAL MEDICAL QUESTIONNAIRE

The dental record is created as part of the treatment: it is protected by law and professional secrecy. It is kept in the practice, and only the dentist and his staff have access to it. The patient also has a right of access and rectification.

Please note that ALL fields must be completed in order to submit your questionnaire. Approximately 3 minutes to complete and submit. Thank you for your cooperation.

PERSONAL & CONTACT INFORMATION

First Name *

Last Name *

Email *

Preferred Name *

Gender * F M O

Preferred Langage * F A

Date of birth *

RAMQ Ins. No. *

Expiration *

Address *

City *

Province *

Postal code *

Home Tel *

Tell/cell *

Work Tel *

Ext *

Emergency Contact Name *

Tell/cell *

Relationship to Patient *

What other family member is seen by us ? *

Whom may we thank for referring you ? *

Dental Informations

Reason of the visit *

Are you anxious about dental treatments ? * Not at all A little Very Much

Do you currently have a Dentist ? * Yes No

Dentist Name *

Last Visit *

Date of last Dental Hygiene & Check-up *

Frequency Covered * 4 mo 6 mo 9 mo

ARE YOU INTERESTED IN A COMPLIMENTARY DIGITAL SMILE EVALUATION ? * Yes No

Have you had or Have Knowledge of, Check all that Apply

Any lumps or swelling in your mouth ? * Yes No

Any complications when given local anesthetic ? * Yes No

Other Relevant Medical Information, Check All that Apply

Do you snore ? * Yes No

Do you smoke? * Yes No

Do you have sleep apnea ? * Yes No

Do you consume any drugs? * Yes No

INSURANCE INFORMATION

PRIMARY Insurance Co.

Policy Holder Name

DOB of Policy Holder

Name of Employer

Group #

Cert. #

Div. #

SECONDARY Insurance Co

Policy Holder Name

DOB of Policy Holder

Name of Employer

Group #

Cert. #

Div. #

PATIENT CONSENT & IDENTIFICATION AND DENTIST’S ACKNOWLEDGMENT

I have filled out this medical-dental questionnaire to the best of my knowledge (Patient/Parent/Guardian) I have reviewed this medical-dental questionnaire & have taken the customary measures, as the case may be (Dentist)

This questionnaire will help the dentist and his/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.

CONFIDENTIAL MEDICAL QUESTIONNAIRE

PERSONAL & CONTACT INFORMATION

Dental Informations

Do you Currently Experience, Check all that Apply

Digital Smile Design (DSD) Evaluation, Check all that Apply

Do you Ever

Do you have

For your Dental Comfort, Check all that Apply

Have you had or Have Knowledge of, Check all that Apply

MEDICAL HISTORY

Allergies to medications, foods and others (check all that apply)

Existing & Past Medical, Health & Infectious Conditions, Check All that Apply

Other Relevant Medical Information, Check All that Apply

INSURANCE INFORMATION

PATIENT CONSENT & IDENTIFICATION AND DENTIST’S ACKNOWLEDGMENT

Sign here Clear