Last name *
First name *
Date of birth *
Provincial health insurance no
Expiration
Address *
City *
App.
Postal code *
Phone - home
Phone - work
Phone - cellular
Referred by
Person in charge (if patient is minor)
RoleFatherMotherGuardianOther
Email *
Occupation
Dental insuranceyesno
Company
Policy Num.
Certificate Num.
Name of insured
Date of birth (of insured)
Are you currently under the care of a physician ? yesno
Name of your doctor :
Speciality :
Frequency of follow-ups :
Reason :
Have you been hospitalized in the past 2 years? yesno
Year :
Do you use Tobacco, Vaper, Drug, Alcohol ?yesno
Specify:
Frequency of use :
Woman
Are you pregnant?yesno
how many weeks
Do you take birth control pills?yesno
Are you menopausal ?yesno
Do you suffer or have you suffered from :
Cardiac disorders (Infarction, Angina, Arrhythmia, Heart murmur, Endocarditis, Valve disease)yesno
Blood pressure disorders (High or Low)yesno
Vascular disorders (ACV, Thrombophlebitis)yesno
Blood disorders (Hemophilia, Anemia, Mononucleosis)yesno
Pulmonary disorders (Asthma, Emphysema, Tuberculosis, COPD)yesno
Liver Disorders (Jaundice, Hepatitis A, B, C, Cirrhosis)yesno
Digestive disorders (gastric reflux, stomach ulcer, Crohn's disease)yesno
Thyroid Disorders : (Hypothyroidism / Hyperthyroidism)yesno
Kidney Disorders (Kidney Failure, Kidney Stone)yesno
Neurological disorders (epilepsy, Parkinson's)yesno
Multiple sclerosis ?yesno
Cognitive and learning disorders (HAT, ADHD, Autism, PDD)yesno
Psychiatric disorders (Depression, Anxiety, Schizophrenia, bipolarity)yesno
Inflammatory diseases (Arthritis, Rheumatoid Arthritis)yesno
Osteoporosis ?yesno
Prevention/treatment (by tablets) ?yesno
Annual or monthly injection ?yesno
Infections transmitted by blood and saliva (STBBIs/STDs)yesno
Specify the infection :
Are you HIV positive ?yesno
Rheumatic Feveryesno
Diabetes (Type I or Type II)noType IType II
Sinusitis, chronic rhinitisyesno
Eye problem (Glaucoma)yesno
Cancer (tumor)yesno
Year
Treatments : (Chemotherapy/Radiotherapy) ?
Have you ever had a transplant ?yesno
Transplant year
Transplant location
Do you have one or more joint prostheses ? (Hip, knee) yesno
For how many years
Do you follow a special diet ?yesno
Do you have Acquired Immune Deficiency Syndromeyesno
Do you have frequent headaches, migraines, Earachesyesno
Loss of consciousness, dizziness yesno
Snoring or sleep apneayesno
Do you have a CPAP ? yesno
Abnormal weight loss or gain, Anorexia, difficulty swallowingyesno
Significant fatigue or stressyesno
Skin problem (Psoriasis, Eczema, Other)yesno
Hay fever / Seasonal allergiesyesno
Do you suffer from dry mouth ?yesno
Do you take or have you ever taken bisphosphates to treat an illness ?yesno
Do you take medication, natural or homeopathic products ? yesno
medication, natural or homeopathic infos
Drug name
Mg/day
Disease treated
Have you ever had an allergic reaction to the following products :
Latexyesno
Aspirin / Ibuprofen / Acetaminophenyesno
Penicillinyesno
Sulfonamidesyesno
Codeineyesno
Iodineyesno
Local anesthesiayesno
Foodyesno
Others
I, undersigned, declare having read, understood, and informed myself and have responded to the best of my knowledge to the medical questionnaire. I hereby take the responsibility to advise you of any change in my health. Patient initials:
I agree to contact Centre Dentaire Griffin at least 48 hours before appointment time if my appointment has to be changed. (This time is reserved for you. Fees of 60$ for each hour missed will be applied to your account for non-compliance with this policy.). Patient initials:
