Confidential medical-dental questionnaire - Centre Dentaire Cousineau

First Name *

Last Name *

Visit Date *

Personal Information

Gender *

Date of birth, YY/MM/DD *

If under 18, enter the surname and first name of the parent / guardian

Relationship with the patient

In case of emergency, contact: Name, first name, telephone number: *

Quebec health insurance card number *

Quebec health insurance card expiry date : YY/MM *

For the terms and conditions of direct sending to private insurance, please refer to our policy which can be found in the Welcome email from our dental center.

Private dental insurance * Optional NAME OF YOUR PRIVATE INSURANCE / POLICY NUMBER / GROUP NUMBER

Cell phone *

Home telephone number

Work telephone Number

Email *

Address *

City *

Province *

Postal code *

Referred by *

Medical history

Are you currently under the care of a physician? *

NoYesNo

Name of your family doctor and telephone number & Name of your specialist doctor and telephone number

Have you ever been operated on or hospitalized? If yes, specify; reason, details, date. *

NoYesNo

Do you have any artificial joints? *

NoYesNo

Did you have a weight loss or gain lately? *

NoYesNo

Are you pregnant ? *

NoYesNo

Are you breastfeeding? *

NoYesNo

Are you presently taking natural or homeopathic products? *

NoYesNo

Are you taking birth control pills? *

NoYesNo

Are you taking hormones? *

NoYesNo

LIST OF MEDICINES

You can send your list of medications to :

Email: cdentairecousineau@gmail.com

or by fax: 450-676-8433

Do you take medication ? If yes, specify; the name of the drug and the reason. *

NoYesNo

Do you suffer from hay fever? *

NoYesNo

Do you suffer from seasonal allergy ? *

NoYesNo

Allergy or manifestation with products containing :

Latex ? *

NoYesNo

Penicillin ? *

NoYesNo

Other antibiotics ? *

NoYesNo

Codeine ? *

NoYesNo

Aspirin ? *

NoYesNo

Sulfonamides ? *

NoYesNo

Iodine-containing products ? *

NoYesNo

Local anesthetic ? *

NoYesNo

Food ? *

NoYesNo

Other ? *

NoYesNo

Do you wish to discuss your health privetaly with your dentist ? *

NoYesNo

Other medical conditions that should be mentioned ? *

NoYesNo

Conditions médicales

Please check Yes or No for each current or past condition

Chronic pain ? *

NoYesNo

Cancer (tumour) Specify *

NoYesNo

Radiotherapy *

NoYesNo

Chemotherapy ? *

NoYesNo

Heart conditions; heart attack, angina, surgery, ect. *

NoYesNo

Heart infection (endocarditis) ? *

NoYesNo

Surgery to replace or repair a valve / cusp ? *

NoYesNo

Lung disorders ? *

NoYesNo

Asthma ? *

NoYesNo

Arthritis *

NoYesNo

Osteoporosis *

NoYesNo

Osteoporosis - Prevention / treatment (e.g.: tablets) *

NoYesNo

Osteoporosis injection

Earaches *

NoYesNo

Eye disorders *

NoYesNo

Skin diseases *

NoYesNo

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

NoYesNo

Thyroid disorders *

NoYesNo

Kidney disorders *

NoYesNo

Stomach disorders (ulcer, reflux) Specify *

NoYesNo

Digestive system disorders or diseases. Specify *

NoYesNo

Liver disorders (hepatitis A, B, C. cirrhosis, ect.) Specify *

NoYesNo

Frequent headaches *

NoYesNo

Nervous system disorders or diseases *

NoYesNo

Mental disorders or illnesses *

NoYesNo

Frequent colds or sinusitis *

NoYesNo

Epilepsy *

NoYesNo

Dizziness *

NoYesNo

Fainting *

NoYesNo

Blood pressure *

Blood disorders (hemophilia, anemia, prolonged bleeding) *

NoYesNo

Do you suffer from sleep apnea ? *

NoYesNo

Other aspects

Do you drink alcohol? *

NoYesNo

Frequency drinks

Do you take drugs *

NoYesNo

Do you take methadone *

NoYesNo

Do you use cannabis *

NoYesNo

How often do you use cannabis

I have never smoked tobacco products (cigarette, cigar, pipe, etc.) *

NoYesNo

I have smoked tobacco products in the past but quit. Enter how many months or years ago. *

NoYesNo

Currently I smoke ... cigarettes a day

When I wake up, I smoke my first cigarette after ... minutes

Do you plan to quit smoking within the next 30 days?

NoYesNo

Would you like help quitting smoking?

NoYesNo

Diabetes

Are you diabetic? If so for how many years? *

NoYesNo

Type of diabetes

Do you think your diabetes is well balanced?

NoYesNo

How often do you have your blood sugar checked?

Are there diabetics in your family? *

Have you ever had any of the following symptoms? Frequent urination, excessive thirst, weakness and fatigue, excessive hunger, slow healing, blurred vision, unexplained weight loss, tingling or numbness in the limbs. *

NoYesNo

Dental information

Reason for today's visit *

Do you fear dental treatments ? *

Last visit ? *

Treatment(s) received *

At your last exam, were there any treatments to do that were not completed? *

NoYesNo

Are your teeth sensitive? *

Is there something about your teeth that bothers you? *

Have you noticed bleeding from your gums? *

NoYesNo

Have you ever been treated for a gum problem? *

NoYesNo

Does anyone in your family have a gum problem? *

NoYesNo

Have you noticed if one or more teeth have shifted over time? *

NoYesNo

Does food get stuck between your teeth? *

NoYesNo

Do you snore at night? *

NoYesNo

Do you suffer from dry mouth? *

NoYesNo

Pain in the jaw joint? *

NoYesNo

Oral habits

Flea sucking (fingers) *

NoYesNo

Mouth breathing (mouth breathing) *

NoYesNo

Diction disorder? *

NoYesNo

Clenching of teeth? *

NoYesNo

Grinding of teeth? *

NoYesNo

Cousineau Dental Center policy

I understand and accept the policies of the Cousineau Dental Center *

NoYesNo

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :

Confidential medical-dental questionnaire - Centre Dentaire Cousineau

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Thanks for completing the form.

The information has been received.

Did you enjoy the Colib experience?

Click the link below to learn how Colib can help you and your company with digital forms.

Personal Information

Medical history

Conditions médicales

Diabetes

Dental information

Cousineau Dental Center policy

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