Medical questionnaire

Today, dentistry is an integral part of medicine. In order to treat you safely and provide you with the best possible dental care, we need you to provide us with a certain amount of essential information about your health, any medication you may be taking and the condition of your teeth.

So please answer the following questions carefully. It should only take a few minutes, and it will be a great help to us.

So please answer the following questions carefully. It should only take a few minutes, and it will be a great help to us.

Ms.MissMr

Date of birth

Name

First name

Profession

Postal address

Mobile phone/fix

E-mail address

Name of your attending physician

When was your last
medical examination?

Do you have a particular health problem to report?

YesNo

Please tick each of the following diseases or problems you may have had in the past or have at present: (Answers will be completed during the interview with the Dentist).

Antidepressants

Asthma

Cosmetic surgery

Hormonal disorders

Diabetes

Glaucoma

Hepatitis A, B or C

Congenital heart defects

Stomach ulcers

Liver disease

Heart disease

Blood disease

Malignant tumor

Edema (swelling)

Pacemaker

Have you ever experienced abnormal bleeding during an operation or accident?

YesNo

Have you undergone radiation treatment (radiotherapy)?

YesNo

Prenez-vous des médicaments en ce moment ?

OuiNon

If so, which ones?

Antibiotics

Aspirin

Insulin

Cortisone

Antihistamine

Other

Êtes-vous allergique à certains produits ou médicaments ?

OuiNon

If so, which ones?

Local anesthetic for dentists

Antibiotic

Iodine and by-products

Latex

Neuroleptic or sleeping pill

Metal

Barbiturates

Codeine

If you think you have any other illness or problem not listed above that could help us to treat you in the best possible conditions, please let us know.

Êtes-vous fumeur ?

OuiNon

If yes,
number of cigarettes/day

Madame, Mademoiselle, êtes-vous enceinte ?

OuiNon

If yes,
number of cigarettes/day

Are you taking any treatment for osteoporosis or other bone disease (Didronel, Clabostan, Lytos, Skelid, Aredia, Fosamax, Fosavance, Actonel, Bonviva, Bondranat, Zometa, Aclasta)?

YesNo

I certify that this document is accurate and that nothing has been omitted. I will notify you immediately of any changes in my state of health or medical prescriptions.

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