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MEDICAL QUESTIONNAIRE

Please complete this confidential questionnaire prior to your first visit.

Sex

Have you ever suffered from... or do you suffer from...?*

Diabetes
Heart attack or angina
Endocarditis (inflammation of the heart)
Heart valve abnormalities
Heart murmur or heart defect
High blood pressure
Low blood pressure
Thrombophlebitis / pulmonary embolism
Hemorrhage
Asthma or chronic bronchitis
Tuberculosis
Other pulmonary conditions
Digestive disease
Stomach ulcer
Acid reflux
Kidney disease
Thyroid disease
Liver disease
Hepatitis or other viral disease
Arthritis
Epilepsy or convulsions
Osteoporosis
Sexually transmitted or blood-borne infection
Cancer
Radiology treatment for cancer
Chemotherapy treament for cancer
Sleep apnea
Could you currently be pregnant?
Are you allergic to... Penicillin
Sulfonamides
Aspirin
Codeine
Anti-inflammatories
Latex
Are you taking any medication (prescription, over the counter or herbal)?
Have you taken cortisone in the past 6 months?
Have you ever undergone surgery?
Have you ever been hospitalized?
Do you smoke tobacco?
Do you use drugs?
I accept that any photographs and x-rays taken during my treatment may be used for educational purposes, publications and/or on social media (Facebook, Instagram)

The dental file is created as part of the care that will be provided. It is protected by law and professional secrecy. It is kept in the office and only the dentist and the staff have access to it. The patient also has the right to access and rectify it.

I have completed this questionnaire to the best of my knowledge. This questionnaire will allow the dentist and the staff to provide the best possible care and reduce the risk of any medical complication(s). As a patient, it is in my interest to respond carefully and to notify the dentist of any change in the state of my health.

Thank you for filling out the questionnaire

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Personal information protection: Dr. Anne-Frédérique Chouinard is the Privacy Officer for Maxillo Tandem: info@maxillotandem.com

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