Patient Area | Clinique de parodontie de l'Outaouais

Name First name Last name

Enter your first and last name.

Date of birth / DD / MM YYYY

Enter your date of birth.

Sex F M

Contact Information

Address

City

Province

Postal Code

Entrer your contact information.

Home phone number - (###) - ### ####

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Office phone number - (###) - ### ####

Enter your office phone number.

Employer

Enter the name of your employer.

Main complaint

Enter your main complaint.

Dental Insurance Yes No

Do you have dental insurance?

Dental Insurance Company

Enter the name of your dental insurance company.

1. Are you or have you ever been under the care of a physician during the past year? Yes No

2. Are you taking any drugs or medications (including birth control) ? Yes No

3. Have you had an unusual reaction to any drugs or medication? If so, what drugs or medication? Yes No

Description

Describe your unusual reaction to any drugs or medication.

4. Have you ever experienced any bleeding or clotting problems? Yes No

5. Have you ever been hospitalized or have had surgery other than dental surgery? If so, indicate what kind of surgery. Yes No

Description

What other surgery have you had?

6. Women : Are you pregnant ? Yes No

7. Do you smoke or have you ever smoked? Yes No

Check any of the following which you have had or have at the present

Allergies Anemia Arthritis Asthma Cancer/Cancer treatment Chest pain Chronic bronchitis Congenital heart trouble Diabetes Emphysema Epilepsy Fainting/Dizziness Glaucoma Hay fever

Heart murmur Heart trouble Hepatitis/jaunndice High blood pressure Kidney disease Liver disease Rheumatic fever/scarlet fever Sinus trouble Stroke Thyroïd disease Tuberculosis Ulcers Sexually Transmitted Infection (STI)

Check any of the following which you have had or have at the present.

Remarks

Enter any and all remarks that could be related to the previous question.