Clinique MFML – Protocole

YOUR INFORMATIONS

Gender*

M
F

First Name*

Last Name*

Address*

Address Address 2 City Province Postal code

Tel. home*

Tel. work

Tel. mobile

Email*

Date of birth (DD/MM/YYYY)*

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

Blood pressure*

Yes - High
Yes - Low
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

Gastric problems*

No
Yes - Ulcer
Yes - Reflux

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*

No
Radiotherapy
Chemotherapy

Sleep apnea*

Yes
No

HISTORIQUE MÉDICALE

Are you or could you be pregnant*

Yes
No

Are you allergic to:*

No
Penicillin
Sulfonamides
Aspirin
Codeine
Anti inflammatory
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

is Approval

Who is this for?

Me