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Dental implants
Wisdom teeth
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Oral pathology
Traumatology
3D Radiology
Our clinic: who are we?
Team
Dr. Mathieu Lenis, DMD, FRCD(C)
Patients
Preoperative Instructions
Postoperative Instructions
Confidential Medical Questionnaire
COVID-19 Questionnaire
Professionals
Referral Form
Login « Intranet/ partnership zone »
Blog
Contact
Services
Dental implants
Wisdom teeth
Complex extractions
Intravenous sedation
Orthognathic surgery
Oral pathology
Traumatology
3D Radiology
Our clinic: who are we?
Team
Dr. Mathieu Lenis, DMD, FRCD(C)
Patients
Preoperative Instructions
Postoperative Instructions
Confidential Medical Questionnaire
COVID-19 Questionnaire
Professionals
Referral Form
Login « Intranet/ partnership zone »
Blog
Contact
Confidential medical questionnaire
YOUR INFORMATION
Gender
*
M
F
First Name
*
Last Name
*
Address
*
Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal code
Tel
*
Tel. work
Other tel
Email
*
Date of birth (DD/MM/YYYY)
*
Day
1
2
3
4
5
6
7
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9
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11
12
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31
Month
1
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12
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Medical number (optional)
Expiration
Occupation
Your dentist
Your orthodontist
Reason for visit
*
What I would like to correct
ARE YOU SUFFERING OR HAVE YOU SUFFERED FROM...?
Diabetes
*
Yes
No
Infarction or angina
*
Yes
No
Endocarditis (heart infection)
*
Yes
No
Valvular disease
*
Yes
No
Heart murmur or Heart defect
*
Yes
No
High blood pressure
*
Yes
No
Low blood pressure
*
Yes
No
Thrombophlebitis / Pulmonary embolism
*
Yes
No
Prolonged bleeding
*
Yes
No
Asthma or Chronic obstructive pulmonary disease
*
Yes
No
Tuberculosis
*
Yes
No
Other pulmonary disease
*
Yes
No
Digestive disease
*
Yes
No
Ulcer
*
Yes
No
Reflux
*
Yes
No
Renal disease
*
Yes
No
Thyroid disease
*
Yes
No
Liver disease
*
Yes
No
Hepatitis or Other viral infection
*
Yes
No
Arthritis
*
Yes
No
Epilepsy or Seizure
*
Yes
No
Osteoporosis
*
Yes
No
Cancer
*
Yes
No
Radiotherapy
*
Yes
No
Chemotherapy
*
Yes
No
Sleep apnea
*
Yes
No
MEDICAL HISTORY
Are you or could you be pregnant
*
Yes
No
Are you allergic to:
*
No known allergies
Penicillin
Sulfonamides
Aspirin
Codeine
Anti inflammatory
Latex
Other
Specify others
*
Are you taking any medications or natural products?
*
Yes
No
If yes, which ones:
*
Have you taken cortisone in the last 6 months?
*
Yes
No
Have you undergone surgery?
*
Yes
No
If yes, other than dental:
*
Have you ever been hospitalized?
*
Yes
No
If yes, when and what for?
*
Are you taking/using:
Tobacco products
*
Yes
No
If yes, number per day:
*
Alcohol
*
Yes
No
If yes, number per week:
*
Illicit drugs
*
Yes
No
If yes, what kind?
*
Other health conditions not mentioned
ACCEPTANCE
Acceptance of medical history
*
I, the undersigned, hereby declare that I have read, understook and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Clinique MFML. I have been informed that my file will be kept in the office at all the time and that only the dentist and it’s auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.
Publication Acceptance
I consent for my photographs taken during my visit(s) to be used for teaching and publication puroses.
Patient or Guardian Signature
*
Date
RESERVED FOR ADMINISTRATION
Notes
Precautions
Acceptance of the specialist
*
I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.
Specialist Signature
Specialist Name
*
Date
MM slash DD slash YYYY
Hidden
is Approval
Who is this for?
Me
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