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Dr. Mathieu Lenis, DMD, FRCD(C)
Dr Elliot Saleh DMD, FRCDC ABOMS
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Services
Our services
Dental Implants
Wisdom teeth extraction
Complex extractions and other oral surgeries
Pathology
Intravenous Sedation
Orthognathic surgery
3D Imaging
Client hub
About
About
Dr. Mathieu Lenis, DMD, FRCD(C)
Dr Elliot Saleh DMD, FRCDC ABOMS
Blog
Refer a patient
Contact us
EN
FR
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Confidential medical questionnaire
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Your information
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Full name
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Last name
First name
Address
Street Address
City
Province
Postal code
Cell phone
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Work phone
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Email
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Date of birth
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DD slash MM slash YYYY
Occupation
Health insurance number (optional)
Expiry date
Your dentist's name
Your orthodontist's name
Reason for visit
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What I would like to correct
Have you had, or do you have, any of the following?
Diabetes
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Yes
No
Heart attack or angina
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Yes
No
Endocarditis (heart infection)
*
Yes
No
Heart valve abnormality
*
Yes
No
Heart murmur or congenital heart defect
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Yes
No
High blood pressure
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Yes
No
Low blood pressure
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Yes
No
Thrombophlebitis / Pulmonary embolism
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Yes
No
Hemorrhage, prolonged bleeding
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Yes
No
Asthma or chronic bronchitis
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Yes
No
Tuberculosis
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Yes
No
Other lung problem
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Yes
No
Digestive disease
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Yes
No
Ulcer
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Yes
No
Reflux
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Yes
No
Kidney disease
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Yes
No
Thyroid disorder
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Yes
No
Liver problem
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Yes
No
Hepatitis or other viral disease
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Yes
No
Arthritis
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Yes
No
Epilepsy or seizures
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Yes
No
Osteoporosis
*
Yes
No
Cancer
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Yes
No
Medical history
Could you currently be pregnant?
*
Yes
No
Have you ever had an allergic reaction or other reaction to the following products:
No known allergies
Penicillin
Sulfonamides
Aspirin
Codeine
Anti-inflammatory
Latex
Other
Specify other
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Do you take any medications or natural products?
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Yes
No
If yes, current list
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Have you taken cortisone in the past 6 months?
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Yes
No
Have you ever had surgery?
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Yes
No
If yes, why?
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Have you ever been hospitalized?
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Yes
No
If yes, why?
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Do you use:
Tobacco
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Yes
No
If yes, indicate the number of cigarettes per day:
*
Alcohol
*
Yes
No
If yes, indicate the number of drinks per week
*
Drugs
*
Yes
No
If yes, which ones?
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Consent
Medical history consent
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I, the undersigned, declare that I have read, understood, informed myself, and answered the medical-dental questionnaire to the best of my knowledge. I hereby agree to notify you of any change in my health status. I authorize the creation of my dental record, its follow-up, as well as my enrollment on the Clinique MFML recall list. I have been informed that my record will be kept at the office and that only the dentist and their staff will have access to it. I have been informed of my right to consult my record, request a correction, and withdraw from the recall list.
Publication consent
I agree that the photos taken may be used for teaching and/or publication purposes
Date
DD slash MM slash YYYY
Signature
For the treating team only
Notes
Precautions
Specialist consent
I acknowledge that I have reviewed the answers on the registration questionnaire and have taken the usual measures, where applicable.
Specialist's name
Date
MM slash DD slash YYYY
Other medical conditions not listed
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