Confidential Registration Form

Personal Information

Date of Birth :*
Health Ins. No. :
Expiry Date:

Contact Information

Home tel. :*
Work tel. :
Cell phone :

For emergencies, call:

Name of third person:
Relationship to patient:
Main tel. :
Cell. :

Dental Information:

Reason for today's visit:

Do you fear dental treatments?:
Last visit :
With panoramic radiographs (large x-ray) :
With intraoral radiographs (small x-rays) :
This questionnaire will help the dentist and his or her staff provide the best possible care and reduce the risk of medical complications.
It is in the patient’s best interest to carefully fill it out and notify the dentist of any change in their health condition.

Medical history:

Are you being treated by a physician? :*
Reason, details and date:(1)
Have you ever had surgery or been hospitalized? :*
Reason, details and date:(2)
Do you have joint prostheses (hip, knee, etc.)? :*
Reason, details and date:(3)
Have you gained or lost a lot of weight recently? :*
Reason, details and date:(4)
Are you pregnant? :*
Are you breastfeeding? :*
Are you taking natural or homeopathic products? :*
Specify :
Are you taking medication? :*
Are you taking birth control, or hormones? :*
Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months:

Please check Yes or No for each current or past condition

Blood disorders(hemophilia, anemia, prolonged bleeding) :*
Heart conditions
Infarction (heart attack), angina, surgery, etc. :*
Heart infection (endocarditis) :*
Surgery to replace or repair a valve /cusp :*
Blood pressure:*
Dizziness, fainting :*
Frequent headaches :*
Jaw pain :*
Liver disorders (hepatitis A, B, C. cirrhosis, etc.) :*
Digestive system disorders or diseases :*
Specify the diseases or the disorders:
Stomach disorder :*
Kidney disorders :*
Diabetes :*
Thyroid disorders :*
Cancer (tumour) :*
Specify the cancer:
Chemotherapy :*
Sexually transmitted or blood-borne infections (STBBI) :*
Specify STBBI:
Skin diseases :*
Eye disorders :*
Earaches :*
Arthritis :*
Osteoporosis :*
Chronic pain :*
Epilepsy :*
Nervous system disorders or diseases :*
Mental disorders or illnesses :*
Frequent colds or sinusitis :*
Tuberculosis or lung disorders :*
Asthma :*
Hay fever / seasonal allergies :*
Allergy or manifestation with products containing:
Latex :*
Penicillin :*
Other antibiotics :*
Codeine :*
Aspirin :*
Sulfonamides :*
Anesthetic :*
Food :*
Iodine-containing products :*
Other medical conditions that should be mentioned:

Other aspects:

Do you snore? :*
Do you suffer from sleep apnea? :*
Do you smoke? :*
How many cig./day?:
ex-smoker? :*
Do you drink alcohol? :*
Frequency :*
Do you take drugs? :*
Do you take methadone? :*

I hereby agree to allow the dentist and his or her staff to obtain information that is relevant to or consistent with the purpose of the file from the health professionals listed above or to disclose such information to these health professionals.

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