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Medical questionnaire

Complete this form to facilitate your first visit.

If you have already scheduled an appointment with us, you can facilitate your first visit by filling out this medical questionnaire and then by clicking the SEND button at the bottom of the page. This confidential information will only be reviewed by your surgeon at the time of your appointment.

If you prefer to print, fill it out by hand and bring it with you at your appointment, click here. You can also send it by email to info@mtlmf.com.

Personal information

Patient's first name

Do you have dental insurance?

Yes

Do you receive social assistance (welfare)?

Yes

Phone (home)

Phone (work)

Ext.

Cell

Preferred modality of communication:

Text message

Telephone

Medical informations

Reason for visit

Who referred you to our office?

Name of your dentist

Height

Weight

Do you drink alcohol?

Yes

How often?

Have you ever been hospitalized or had an operation?

Yes

Do you smoke tobacco?

Yes

How often?

Do you use cannabis products?

Do you use illicit drugs?

Yes

Which kind?

have you ever had or are being treated for the following:

Hepatitis A, B or C

Yes

High Blood Pressure

Yes

Liver Disease

Yes

Kidney Disease

Yes

Osteoporosis

Yes

Tendency to Faint

Yes

Heart Disease

Yes

Gastrointestinal Disorders

Yes

Thyroid Disease

Yes

Are you pregnant?

Yes

Are you breastfeeding?

Yes

Allergies, medications and other information

Are you allergic to, or have ever had an unusual reaction to any of the following?

General Anaesthesia

Yes

Codeine

Yes

Dental Injections

Yes

Latex

Yes

Penicillin

Yes

Other antibiotics

Other medications

Please list any medications you are presently taking
(attach list if required)

Do you wish to add any other information with regard to your general health status?

Is there additional information you wish to share to help us make your care more pleasant?

Attach files
(list, report, referral or other)

Name of person who completed this form

Relation to patient if other