top of page


Please complete this confidential questionnaire prior to your first visit.


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

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
Asthma or chronic bronchitis
Other pulmonary conditions
Digestive disease
Stomach ulcer
Acid reflux
Kidney disease
Thyroid disease
Liver disease
Hepatitis or other viral disease
Epilepsy or convulsions
Sexually transmitted or blood-borne infection
Radiology treatment for cancer
Chemotherapy treament for cancer
Sleep apnea
Could you currently be pregnant?
Are you allergic to... Penicillin
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

  • Instagram
  • Facebook
  • LinkedIn

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

bottom of page