Medical-Dental Questionnaire Ortho Laval, Orthodontist in Laval -

Patient information

Man

Women

Other

Last name of the patient*

First name of the patient*

Email of the patient*

Are you a beneficiary of a social assistance program in Quebec?

Yes

Address

Adress and apartment*

City*

Postal code*

Home phone

Cell phone

Office phone

Post

Birth date

Year*

Month*

Day*

Health insurance number

Expiry

If you are under 18, write the name of the parent

OR guardian

referred by

Costs and fees manager

Himself*

Yes

Name (of) responsible

First name (of) responsible

Address

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Dental informations

Reason for visit*

Do you fear dental treatment? Specify:*

A little

A lot

Not at all

Last visit:*

0 to 6 months

6 to 12 months

+ 12 months

What is the full name of the attending dentist?*

Treatment(s) received:

With panoramic dental radiography (large X-ray)*

Yes

With intraoral dental X-rays (small x-rays)*

Yes

Have you ever had dental treatments such as

Oral hygiene demonstration*

Yes

Gum treatment*

Yes

Orthodontic Treatment*

Yes

Root canal treatment*

Yes

Shutter*

Yes

Crown and / or bridge*

Yes

The tonsils were they removed*

Yes

Adeid (vegetations) were they removed*

Yes

Do you have a nasal septum deviation*

Yes

Do you have difficulty breathing through the nose*

Yes

Have you ever received a call on your teeth*

Yes

Do you suck your thumb or finger?*

Yes

Complete and / or partial dentures*

Yes

Oral surgery or extractions Treatment*

Yes

Dental implants*

Yes

Dental x-rays*

Yes

Gnaw your nails yourself?*

Yes

Do you get anyed about your teeth?*

Yes

Do you grind your teeth at night?*

Yes

Did you have a consultation with an orthodontist? If so, which?*

Yes

Information on growth (for children 10-14 years)

Is your child in active growth period?*

Yes

N/A

Does your child seem to have reached puberty?*

Yes

N/A

Girls only*

Are you taking birth control pills (oral contraceptives)?*

Yes

Do you take hormones? Specify:*

Yes

Are you pregnant?*

Yes

Do you breastfeed?*

Yes

Have menstruation started? If so, how long?*

Yes

N/A

Medical history

Are you actually under a doctor's care? If so, reason:*

Yes

Doctor's name

Doctor's phone

Post

Are you taking natural or homeopathic products?*

Yes

Have you gained or lost a lot of weight lately?*

Yes

Are you taking any medications or have you taken any in the last 6 months? If yes, which ones:*

Yes

Are you taking anovulants or hormones?*

Yes

Please indicate all medications (including anovulants and hormones) taken at this time or in the past 12 months*

Have you ever been hospitalized or undergone surgery other than dental? If yes, specify*

Yes

Have you suffered or are you suffering from:

Cardiac disorders (heart attack, angina, endocarditis, valve problems, breath)*

Yes

Rheumatic fever*

Yes

Jaw pain*

Yes

Dryness of the mouth*

Yes

Blood problems

Haemophilia*

Yes

Prolonged bleeding*

Yes

Bright blood*

Yes

Blood pressure (High or low). If yes, specify*

Yes

Anemia*

Yes

Other, specify*

Yes

Frequent colds or sinusitis*

Yes

Pulmonary tuberculosis or problems*

Yes

Digestive disorders, specify*

Yes

Stomach ulcer*

Yes

Liver problems (hepatitis: viruses A, B, C, etc.)*

Yes

Kidney disorders*

Yes

Urinate you often?*

Yes

Sexually transmitted diseases (STDs)*

Yes

Diabetes*

Yes

Thyroid problems*

Yes

Skin disease*

Yes

Eye problems*

Yes

Do you take bisphosphonates?*

Yes

Epilepsy*

Yes

Nervous disorders*

Yes

Psychiatric diseases, specify whether*

Yes

Dizziness, fainting*

Yes

Earaches*

Yes

Hay fever*

Yes

Asthma*

Yes

Arthritis*

Yes

Osteoporosis*

Yes

Chronic Pain*

Yes

Have you ever had radiation treatment and / or chemotherapy (tumor)?*

Yes

Do you have any artificial joints (hip, knee, etc.)?*

Yes

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

Latex*

Yes

Foodstuffs. If yes, which ones:*

Yes

Iodine*

Yes

Aspirin*

Yes

Sulfonamides*

Yes

Penicillin*

Yes

Codeine*

Yes

Other antibiotics or medications. If yes, which ones:*

Yes

Local anesthesia*

Yes

Other, specify*

Yes

Would you like to discuss your health with your private dentist?*

Yes

Other aspects

Do you sore or does one ever told you that you sore?*

Yes

Do you suffer from sleep apnea?*

Yes

Do you smoke? If yes, how much per day*

Yes

Do you consume alcohol?*

Little or no

In moderation

A lot

Do you use drugs?*

Yes

Do you take methadone?*

Yes

Note or other medical conditions to mention

Is there any other information we haven't asked for that might be useful? If so, please explain:*

Yes

Orthodontic history

Did you consult another orthodontist?*

Yes

When?

Were you seen in this office before?*

Yes

When?

Have you ever worn "braces" or retainers?*

Yes

When?

Has anyone in your family received orthodontic care (braces)? If yes, which ones:*

Yes

Does your mouth or problem resemble that of others in your family?*

Yes

Patient: How would you rate your concern for the correction of your orthodontic problem?*

Very concerned

Concerned

Opposed

Don't know

Indifferent

Motivated

Parent: How would you rate your concern for the correction of your orthodontic problem?*

Very concerned

Concerned

Opposed

Don't know

Indifferent

Is there any other information we did not ask that you feel would be helpful to us? If so, please explain:*

Yes

Consent to communicate with a health professional

List of my generalist doctor(s), specialist doctor(s), pharmacist, other

Name

Function

Establishment

Telephone

Patient or guardian signature

Delete signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.

Confidential and Secure Health Questionnaire

Patient information

Address

Birth date

Costs and fees manager

Address

Dental informations

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

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

Other aspects

Orthodontic history

Consent to communicate with a health professional

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