• Clinique Dentaire Dr. Fritz Dimitri Joseph
  • Clinique Dentaire Dr. Fritz Dimitri Joseph
  • Clinique Dentaire Dr. Fritz Dimitri Joseph

Patient Zone

Follow up Care at Home

First Visit Form

When you come in for your first appointment, you will have to fill out a form giving us all the relevant information on your health. To speed things up, please fill out the form ahead of time and send it to us on line or print it and bring it with you. Rest assured that all information will remain confidential.

Appointment cancellations must be made by telephone or e-mail at least 48 hours in advance or a service charge will apply.

Personal Information
Last name:
First name:
Sex: F     M
Address:
City:
Postal code:
Home telephone No:
Work telephone No:    Ext: 
Cell.:
E-mail:
Birth date:       Year: 
Medicare Card No:
Expiry: Year:     
Social Insurance No. (optional):
If you are less than 18 years old, indicate name of parent/guardian:     Parent or Guardian
   M Mrs
In case of emergency call:
Reason for visit:
Referred by:
Medical History
Weight:      
Height:      
Are you currently under the care of a physician? yes    no
If so, reason: 
Physician's name: 
Physician's Telephone No: 
Are you currently taking or have you taken any medication in the last six months? yes    no
If yes, please describe them below:
Are you presently taking natural or homeopathic products? yes    no
Specify:
Are you taking birth control pills? yes    no
Hormones? yes    no
Specify:
Did you have a weight loss or gain lately? yes    no
Are you pregnant? yes    no
Are you breastfeeding? yes    no
Do you or have you ever had any of the following?
Heart disease (infarction, angina, valve problems, shortness of breath) yes    no
Rheumatic fever yes    no
Blood problems:
Hemophilia yes    no
Prolonged bleeding yes    no
Clear blood yes    no
Anemia yes    no
Others. Specify:
High or low blood pressure
Frequent colds or sinusitis yes    no
Tuberculosis or lung problems yes    no
Digestive problems yes    no
Specify:
Stomach ulcers yes    no
Liver problems (hepatitis A, B, C or cirrhosis) yes    no
Kidney problems yes    no
Do you urinate often? yes    no
Sexually transmitted infections yes    no
Diabetes yes    no
Thyroid problems yes    no
Skin disease yes    no
Vision problems yes    no
Arthritis yes    no
Osteoporosis yes    no
Do you take biphosphonates? yes    no
Epilepsy yes    no
Nerve problems yes    no
Mental illness yes    no
Specify:
Frequent headaches yes    no
Dizziness or fainting yes    no
Earaches yes    no
Hay fever yes    no
Asthma yes    no
Do you smoke?
Have you ever had radiation treatments or chemotherapy? yes    no
Do you have AIDS? yes    no
Have you tested positive for AIDS? yes    no
Do you have any artificial joints? yes    no
Do you snore or have you ever been told that you snore? yes    no
Have you ever had an allergic reaction to any of the following?
Foods yes    no
Latex yes    no
Penicillin yes    no
Aspirin yes    no
Iodine yes    no
Sulpha drugs yes    no
Codeine yes    no
Local anesthetic yes    no
Other antibiotics yes    no
Other products – please specify:
Do you use drugs? yes    no
Do you drink alcohol?
Have you ever been hospitalized or had surgery other than dental? yes    no
If yes, specify the type of surgery and when:
Do you fear dental treatments?
Do you wish to discuss your health privetaly with your dentist? yes    no
Comments
Dental History
Date of last dental visit:    0-6 months    6-12 months    + than 12 months
Treatment received:
Have you had any of the following dental treatments or services?
Oral hygiene demonstration yes    no
Gum treatment yes    no
Orthodontic treatment (braces) yes    no
Root canal treatment yes    no
Fillings yes    no
Crown(s) or bridge(s) yes    no
Full or partial dentures yes    no
Dental surgery or extraction yes    no
Dental implants yes    no
Dental X-rays yes    no
Others yes    no

Thank you for taking the time filling in this form. We are looking forward meeting you on your next meeting.

1670 St-Joseph Boulevard E, Montreal, Quebec, H2J1M9   •   Telephone: (514)526-3294   •   info@fdjdentisterie.com
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