Confidential medical questionnaire YOUR INFORMATIONSGender*MFFirst Name*Last Name*Address* Address Address 2 City AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve-et-LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukon Province Postal code Tel. home*Tel. workTel. mobileEmail* Date of birth (DD/MM/YYYY)*Jour12345678910111213141516171819202122232425262728293031Mois123456789101112Année2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical number (optional)ExpirationOccupationYour dentistYour orthodontistReason for visit*What I would like to correct*ARE YOU SUFFERING OR HAVE YOU SUFFERED FROM...?Diabetes*YesNoInfarction or angina*YesNoEndocarditis (heart infection)*YesNoValvular disease*YesNoHeart murmur or Heart defect*YesNoBlood pressure*Yes - HighYes - LowNoThrombophlebitis / Pulmonary embolism*YesNoProlonged bleeding*YesNoAsthma or Chronic obstructive pulmonary disease*YesNoTuberculosis*YesNoOther pulmonary disease*YesNoDigestive disease*YesNoGastric problems*NoYes - UlcerYes - RefluxRenal disease*YesNoThyroid disease*YesNoLiver disease*YesNoHepatitis or Other viral infection*YesNoArthritis*YesNoEpilepsy or Seizure*YesNoOsteoporosis*YesNoCancer*NoRadiotherapyChemotherapySleep apnea*YesNoHISTORIQUE MÉDICALEAre you or could you be pregnant*YesNoAre you allergic to:* No Penicillin Sulfonamides Aspirin Codeine Anti inflammatory Other Specify others*Are you taking any medications or natural products?*YesNoIf yes, which ones:*Have you taken cortisone in the last 6 months?*YesNoHave you undergone surgery?*YesNoIf yes, other than dental:*Have you ever been hospitalized?*YesNoIf yes, when and what for?*Are you taking/using:Tobacco products*YesNoIf yes, number per day:*Alcohol*YesNoIf yes, number per week*Illicit drugs*YesNoIf yes, what kind?*Other health conditions not mentionedACCEPTANCEAcceptance 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*DateRESERVED FOR ADMINISTRATIONNotesPrecautionsAcceptance 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 SignatureSpecialist Name*Date Format de date :MM slash JJ slash AAAA is ApprovalWho is this for?Me