Medical questionnaire

Last Name

First name

Sex

E-mail

Phone

Telephone (other)

Date of birth

Month

Day

Year

Address

City

Postal Code

Quebec Health insurance number and Expiration date

Name of your family doctor

Name of your dentist

Do you have private dental insurance?

Yes

No

Name of your pharmacy and the city where it is located

Your weight (kg or lbs)

Please answer all of the following questions.

Anesthesia

Have you ever received general anesthesia or intravenous sedation?

Yes

No

If so, was it well tolerated?

Yes

No

Have you had surgery in the past?

Yes

No

If yes, please indicate the type(s) of surgery(s) and the date(s):

Drugs

Are you currently taking any medications, vitamins, or natural products?

Yes

No

List of medications/vitamins/natural products

Medical history

In the following sections: select the relevant conditions. Otherwise, select "No problem…"

If you have had a heart attack, stent placement, or bypass surgery, please indicate the date for each:

If you have a pacemaker, please indicate the date it was implanted:

If you have a psychiatric illness, what is your diagnosis?

If you have already had a stroke, please indicate the date and the treatment received:

Endocrine/Metabolic System - select among the following:

Oncology - do you have a history of cancer?

Yes

No

If so, please provide more information:

Have you ever received any of the following treatments (radiotherapy or chemo)?

None

Head and neck radiotherapy

Radiation therapy in other areas of the body

Chemotherapy

Allergies

Other allergies

Habits

Do you smoke ?

Yes

No

If yes, please indicate how many cigarettes per day, and for how many years:

Do you use cannabis?

Yes

No

If yes, please indicate:

Do you consume alcohol?

Never

Casual

Regularly

If yes, please indicate the number of times per day or per week:

Do you use other drugs?

Yes

No

If so, which ones?

Are there any other health issues or things you would like to discuss with the surgeon?

Signature

Please note that the completed questionnaire is confidential and will be kept exclusively in your file at the clinic, in accordance with privacy laws.

I consent to the Maxillo Mirabel clinic having access to my medical history, laboratory results and medication list in order to ensure my care and follow-up by the oral and maxillofacial surgeon.

Date

Month

Day

Year

Patient Zone

Medical questionnaire

Please answer all of the following questions.

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