Home
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Blog
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- Confidential Medical-Dental Form
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Home
Our Team
Dental Services
Emergencies
Blog
Contact
- Confidential Medical-Dental Form
English

Heure d'ouvertureLundi : 8h à 18h
Mardi au jeudi : 8h à 21h
Vendredi : 8h à 20h
Samedi et dimanche : 9h à 12h Emergency7 jours sur 7
Avec RDV le jour même
(450) 923-1361 Succursale2151 Boulevard Lapinière
Bureau B02 - Portail #1
Brossard, Québec

Search for:

Heure d'ouvertureLundi : 8h à 18h
Mardi au jeudi : 8h à 21h
Vendredi : 8h à 20h
Samedi et dimanche : 9h à 12h Emergency7 jours sur 7
Avec RDV le jour même
(450) 923-1361 Succursale2151 Boulevard Lapinière
Bureau B02 - Portail #1
Brossard, Québec

Home
Our Team
Dental Services
Emergencies
Blog
Contact
- Confidential Medical-Dental Form
English

Home
Our Team
Dental Services
Emergencies
Blog
Contact
- Confidential Medical-Dental Form
English

Heure d'ouvertureLundi : 8h à 18h
Mardi au jeudi : 8h à 21h
Vendredi : 8h à 20h
Samedi et dimanche : 9h à 12h Emergency7 jours sur 7
Avec RDV le jour même
(450) 923-1361 Succursale2151 Boulevard Lapinière
Bureau B02 - Portail #1
Brossard, Québec

Search for:

Confidential Medical-Dental Form

Clinique Dentaire Champlain

Contact Information

ACCESSIBILITY

Free Parking
Located inside of Mail Champlain in Brossard – Portal #1

Our clinic is outfitted to accommodate people in wheelchairs.

ADDRESS

2151 Lapinière Boulevard, office B02, portal 1, Brossard, Qc

TELEPHONE

Bureau : (450) 923-1361

Fax : (450) 671-5871

EMAIL

clchamplain@videotron.ca

Confidential Medical-Dental Form

Complete the confidential medical form below before going to your first appointment. Don’t worry, your information will remain confidential.

For questions regarding the form or any other questions you may have, don’t hesitate to call us. We will be happy to answer you.

CONFIDENTIAL MEDICAL-DENTAL FORM

Complete the form

Step 1 of 6 - PERSONAL INFORMATION

16%

PERSONAL INFORMATION
First Name*
Last Name*
Sex*
- Female
- Male
Date of birth (YY / MM / DD)*
Health insurance number*
Card expiry date
Address
City
Province
Postal code*

CONTACT INFORMATION
Home phone*
Work phone
Cell phone
Email*
In case of emergency, call:
Name*
Relationship to the patient*
Home phone*
Cell phone

DENTAL INFORMATION
Reason for today’s visit*
Do you have any fear of dental treatments?
- None
- Some
- A Lot
Please specify
Last visit
- 0 – 6 months
- 6 – 12 months
- Over 12 months
Treatment(s) received*
With a panoramic dental X-ray (large X-ray)?*
- Yes
- No
With an intraoral X-ray (small x-ray)?*
- Yes
- No

MEDICAL BACKGROUND
1. Would you like to talk about this privately with your dentist?*
- Yes
- No
2. Do you currently have a doctor?*
- Yes
- No
3. Have you ever been operated on or hospitalized?*
- Yes
- No
4. Have you had joint replacements (hip, knee, etc.)?*
- Yes
- No
5. Have you gained or lost a lot of weight recently?*
- Yes
- No
6. Are you pregnant?*
- Yes
- No
7. Are you breastfeeding?*
- Yes
- No
8. Do you take natural or homeopathic products?*
- Yes
- No
9. Are you taking any medication?*
- Yes
- No
10. Are you taking oral contraceptives?*
- Yes
- No
11. Are you taking hormones?*
- Yes
- No
Please Indicate All Drugs (Including Contraceptives and Hormones) Taken At This Time or In the Past 12 Months (Drug and Reason)*

PLEASE CHECK YES OR NO FOR EACH OF THE CONDITIONS, WHETHER CURRENT OR PAST
Blood problems (hemophilia, anemia, prolonged bleeding)*
- Yes
- No
Heart conditions
- Infarction, angina, surgery, etc.
- Heart inflammation (endocarditis
- Valve or bypass surgery
Blood pressure
- High pressure
- Low pressure
Dizziness, fainting*
- Yes
- No
Frequent headaches*
- Yes
- No
Jaw pain or TMJ*
- Yes
- No
Liver problems (hepatitis A, B, C, cirrhosis, etc.)*
- Yes
- No
Disorders or diseases of the digestive system*
- Yes
- No
Please specify*
Stomach problems*
- Yes
- No
Reason Behind*
- Ulcer
- Acid reflux
Kidney disorders*
- Yes
- No
Diabetes*
- Yes
- No
Cancer (tumor)*
- Yes
- No
Please specify*
Treatment applied*
- Radiotherapy
- Chemotherapy
Thyroid disorders*
- Yes
- No
Do you suffer from dry mouth?*
- Yes
- No
Sexually transmitted and blood borne infections (STBBIs)*
- Yes
- No
Please Specify*
Skin diseases*
- Yes
- No
Eye problems*
- Yes
- No
Earaches*
- Yes
- No
Arthritis*
- Yes
- No
Osteoporosis*
- Yes
- No
Please specify
- Prevention / treatment (e.g. tablets)
- Annual or monthly injection
Chronic pain*
- Yes
- No
Epilepsy*
- Yes
- No
Nervous system disorders or diseases*
- Yes
- No
Psychiatric disorders or illness*
- Yes
- No
Frequent colds or sinusitis*
- Yes
- No
Tuberculosis or lung problems*
- Yes
- No
Asthma*
- Yes
- No
Hay fever / seasonal allergies*
- Yes
- No
Allergy or reaction to these products
- Latex
- Sulfamides
- Penicillin
- Anesthetics
- Other antibiotics
- Food
- Codeine
- Products containing iodine
- Aspirin
Specify other allergies:
Other medical conditions that should be mentioned:

OTHER FACTORS
Do you snore?*
- Yes
- No
Do you suffer from sleep apnea?*
- Yes
- No
Do you smoke?*
- Yes
- No
How many cigarettes a day?*
I am an ex-smoker*
- Yes
- No
Do you consume alcohol?*
- Yes
- No
How often? (__ drinks per day/week/month)
Do you take drugs?*
- Yes
- No
Do you take methadone?*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

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Emergency services 7 days a week

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Clinique Dentaire brossard © Site web : SolutionsM

2151 Boulevard Lapinière, Bureau B02 - Portail 1, Brossard, Québec