Confidential Registration Form

Personal Information

Name:*

First

Last

Sex:*

Other

Date of Birth :*

day

month

year

Health Ins. No. :

Expiry Date:

day

month

year

Address:*

Street AddressCityState / Province / RegionPostal / Zip CodeCountry

Contact Information

Home tel. :*

Area Code

Phone Number

Work tel. :

Area Code

Phone Number

Cell phone :

Area Code

Phone Number

E-mail:

For emergencies, call:

Name of third person:

First

Last

Relationship to patient:

Main tel. :

Area Code

Phone Number

Cell. :

Area Code

Phone Number

Dental Information:

Reason for today's visit:

Select:

Specifiy:

Do you fear dental treatments?:

Not at all

A little

Very much

Specify:

Last visit :

0-6 months

6-12 months

+ 12 months

With panoramic radiographs (large x-ray) :

Yes

With intraoral radiographs (small x-rays) :

Yes

This questionnaire will help the dentist and his or 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.

Medical history:

Are you being treated by a physician? :*

Yes

Reason, details and date:(1)

Have you ever had surgery or been hospitalized? :*

Yes

Reason, details and date:(2)

Do you have joint prostheses (hip, knee, etc.)? :*

Yes

Reason, details and date:(3)

Have you gained or lost a lot of weight recently? :*

Yes

Reason, details and date:(4)

Are you pregnant? :*

Yes

Are you breastfeeding? :*

Yes

Are you taking natural or homeopathic products? :*

Yes

Specify :

Are you taking medication? :*

Yes

Are you taking birth control, or hormones? :*

Birthcontrol

Hormones

Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months:

Please check Yes or No for each current or past condition

Blood disorders(hemophilia, anemia, prolonged bleeding) :*

Yes

Heart conditions

Infarction (heart attack), angina, surgery, etc. :*

Yes

Heart infection (endocarditis) :*

Yes

Surgery to replace or repair a valve /cusp :*

Yes

Blood pressure:*

High

Low

Dizziness, fainting :*

Yes

Frequent headaches :*

Yes

Jaw pain :*

Yes

Liver disorders (hepatitis A, B, C. cirrhosis, etc.) :*

Yes

Digestive system disorders or diseases :*

Yes

Specify the diseases or the disorders:

Stomach disorder :*

Ulcer

Reflux

Kidney disorders :*

Yes

Diabetes :*

Type I

Type II

Thyroid disorders :*

Yes

Cancer (tumour) :*

Yes

Specify the cancer:

Chemotherapy :*

Yes

Sexually transmitted or blood-borne infections (STBBI) :*

Yes

Specify STBBI:

Skin diseases :*

Yes

Eye disorders :*

Yes

Earaches :*

Yes

Arthritis :*

Yes

Osteoporosis :*

Prevention / treatment (e.g.: tablets)

Annual or monthly injection

Chronic pain :*

Yes

Epilepsy :*

Yes

Nervous system disorders or diseases :*

Yes

Mental disorders or illnesses :*

Yes

Frequent colds or sinusitis :*

Yes

Tuberculosis or lung disorders :*

Yes

Asthma :*

Yes

Hay fever / seasonal allergies :*

Yes

Allergy or manifestation with products containing:

Latex :*

Yes

Penicillin :*

Yes

Other antibiotics :*

Yes

Which?

Codeine :*

Yes

Aspirin :*

Yes

Sulfonamides :*

Yes

Anesthetic :*

Yes

Food :*

Yes

Iodine-containing products :*

Yes

Other:

Other medical conditions that should be mentioned:

Other aspects:

Do you snore? :*

Yes

Do you suffer from sleep apnea? :*

Yes

Do you smoke? :*

Yes

How many cig./day?:

ex-smoker? :*

Yes

Do you drink alcohol? :*

Yes

Frequency :*

Day

Week

Month

Do you take drugs? :*

Yes

Do you take methadone? :*

Yes

I hereby agree to allow the dentist and his or her staff to obtain information that is relevant to or consistent with the purpose of the file from the health professionals listed above or to disclose such information to these health professionals.

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

Recaptcha Word Verification:

Confidential Registration Form

Address

Hours

Services

Languages

Search