Confidential Health Questionnaire

SSL Secure Connection

Your privacy is very important to us. We are committed to earning your trust by safeguarding your personal information. All the information you provide to us is securely stored and is kept strictly confidential.

IDENTIFICATION




Please enter the date in this format: dd/mm/yyyy










INSURANCE









CONTACT



TODAY'S VISIT


Dentists provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your dentist provide you with the best possible care by informing him of these conditions.

Please check the appropriate response

HEALTH





Do you have, or have you ever had:




TREATMENT



HOSPITALIZATION



MEDICATION



Are you allergic, or have you had any unusual reaction to any of the following?











Do you have, or have you ever had, any of the following?




WOMEN ONLY




PAST AND CURRENT CONDITIONS


DENTAL HISTORY



Have you previously had dental treatments such as:












I, the undersigned, hereby declare that I have read, understood 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 of the attending dentist(s). 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.