| Personal Information (fields marked with an asterisk are mandatory) |
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Last name:*
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First name:*
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Gender:*
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F M Age :
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Address:*
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City:*
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Postal code:*
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Home telephone:*
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Work telephone:*
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Extention:*
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E-mail:*
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Weight:*
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Height:*
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| Birth date:* |
Year:*
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| Medicare Card No:* |
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| Expiry:* |
Year:
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If child, parent’s name:* |
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| In case of emergency call:* |
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| Reason for visiting us: |
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Medical History |
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| Are you currently under the care of a physician?* |
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| If yes, provide his/her name* |
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| Physician’s Tel:* |
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| Are you currently taking or have you taken any medication in the last six months?
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| If yes, please descrive them below:
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| Avez-vous eu une perte ou un gain de poids marqué dernièrement?
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Are you pregnant?
Are you taking a hormonal contraceptive?
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| Do you or have you ever had any of the following:
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| Heart disease (infarction, angina, valve problems, shortness of breath)?
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| Rheumatic fever?
Prolonged bleeding?
Anemia ?
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| Blood pressure?
Frequent colds or sinusitis ?
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| Tuberculosis or lung problems?
Digestive problems ?
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| Stomach ulcers?
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| Liver problems (hepatitis A, B, C or cirrhosis)
Kidney problems?
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| Sexually transmitted infections (STIs)?
Diabetes?
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| Thyroid problems?
Skin disease?
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| Vision problems?
Arthritis?
Epilepsy?
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| Nerve problems?
Frequent headaches?
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| Étourdissements, évanouissements?
Earaches ?
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| Hay fever?
Asthma ?
Do you smoke ?
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| Have you ever had radiation treatments or chemotherapy?
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| Do you have acquired immunodeficiency syndrome (AIDS)?
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| Have you tested positive for AIDS?
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| Do you have any joint prostheses?
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| Have you ever had an allergic reaction to any of the following:
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| Foods
Penicillin
Aspirin
Iodine
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| Sulpha drugs
Codeine
Local anesthetic
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Others:
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Explain:
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| Have you ever been hospitalized or undergone surgery, other than dental surgery?
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If yes, specify the type of surgery and when:
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| Do you wish to discuss your health with the dentist?
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Comments
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Dental History |
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Date of last dental visit:
0-6 months
6-12 months
+than 12 months |
Treatment received
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| Have you had any of the following dental treatments or services?
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| Oral hygiene demonstration?
Gum treatment?
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| Orthodontic treatment (braces)?
Root canal treatment?
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| Fillings?
Crown(s) or bridge(s)?
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| Full or partial prostheses?
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| Dental surgery or extraction?
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| Dental implants?
Dental x-rays?
Others ?
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