Questionnaire

Medical questionnaire

Medical questionnaire (continued)

Allergies

Condition of your mouth

Personal information

Last name ^*

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First name ^*

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Your age ^*

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Your height

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Your weight

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Date of your last visit to the dentist ^*

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Date of your last visit to a general practitioner ^*

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Date of your last health checkup ^*

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Pre-implantation medical questionnaire

1. Are you currently taking any medications?

Yes

If so, which ones and for what treatments (list them all without exception):

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2. Have you had one or more surgeries?

Yes

If so, which ones and when?

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3. Will you suffer from heart disease?

Yes

If so, what type?

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4. Are you at risk for atherosclerosis?

Yes

5. If so, are you taking anticoagulant medication?

Yes

6. Does your blood have trouble clotting?

Oui

Non

7. Do you have a blood disorder?

Yes

8. Do you have high blood pressure?

Yes

9. What is your usual blood pressure? ^*

Your blood pressure ^*

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10. If so, is it balanced by your treatment?

Yes

11. Do you have a severe or transplant-related immune deficiency?

Yes

12. Have you ever had a blood transfusion?

Yes

13. Are you diabetic?

Yes

14. If so, are you insulin-dependent?

Yes

15. Is your diabetes well controlled by your treatment?

Yes

16. What is your usual blood sugar level?

Your sugar level

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17. Do you have a vitamin D deficiency?

Yes

18. Do you suffer from a severe hormonal or kidney disorder?

Yes

Your weight

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19. Have you ever had any of the following illnesses or conditions?

20. Have you ever had radiation or chemotherapy?

Yes

21. Have you ever had radiation therapy to the head and neck area?

Yes

22. Have you ever had or do you currently have viral hepatitis?

Yes

If so, which type?

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23. Have you had a herpes cold sore?

Yes

24. Are you HIV-positive or have AIDS?

Yes

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25. Do you have osteoporosis?

Yes

If so, what medication are you taking?

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26. Have you had a joint replacement?

Yes

27. Do you have any abnormal reactions to these products (allergies, etc.)?

28. Have you ever taken bisphosphonates?

Yes

If so, when?

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29. Do you smoke?

Yes

If so, how many cigarettes per day?

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30. Do you drink alcohol regularly?

Yes

If so, how many times a week?

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31. Do you regularly consume addictive substances other than alcohol or tobacco?

Yes

32. Do you vomit easily?

Yes

33. Do you have frequent and severe headaches?

Yes

34. Do you suffer from nervous disorders?

Yes

35. Are you experiencing any discomfort?

Yes

36. Do you suffer from seizures?

Yes

37. Do you suffer from irritability?

Yes

38. Do you suffer from any other illnesses or conditions not listed in this questionnaire?

Yes

If so, which ones?

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39. Do you have anything else to add about your general health?

Yes

If so, what?

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40. Did you experience any complications following local anesthesia?

Yes

If so, what were they?

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41. Have you experienced any complications during dental treatment?

Yes

If so, what were they?

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42. Have you ever experienced complications following or during a tooth extraction? (prolonged bleeding, alveolitis, etc.)

Yes

If so, what were they?

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43. Do you tend to grind your teeth?

Yes

Additional questionnaire for female patients

44. Are you or do you think you might be pregnant?

Yes

If so, how many months pregnant are you currently?

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45. Are you taking birth control?

Yes

46. Are you menopausal?

Yes

47. Are you taking hormone replacement therapy?

Yes

48. Have you had a hysterectomy?

Yes

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Allergies

1. Do you have any allergic reactions?

Yes

2. Have you undergone testing to identify your allergy triggers?

Yes

If so, was it a blood test or a skin test?

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3. What allergy do you have?

To medications

Anesthetics?

Yes

Which one?

Antibiotics?

Yes

Which one?

Painkillers?

Yes

Which one?

Aspirin?

Yes

Which one?

To metals

Nickel (typical sources: jewelry, watch straps, clothing fasteners, cosmetics, among others).

Yes

Cobalt chloride (typical sources: blue and black pigments, paints, hair dyes, antiperspirants, eyeglass frames, among others).

Yes

Copper (jewelry, IUDs, among other things)

Yes

Titanium (pacemakers, eyeglass frames, certain types of dental implants).

Yes

Have you had a metal hypersensitivity test?

Yes

If so, which one?

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5. Have you had any hypersensitivity reactions to medical devices?

Yes

If so, which ones:

Metal prosthesis

Intrauterine device

Dental implants

Other

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6. Do you have an autoimmune disease?

Yes

If so, which one?

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7. Do you have skin conditions?

Yes

If so, which ones:

Eczema

Psoriasis

Atopic skin

Other

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CONDITION OF YOUR MOUTH

1. Have you ever had a complete X-ray examination of all your teeth?

Yes

2. Have you ever had treatment for your gums?

Yes

Which ones:

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3. Do you have trouble chewing your food?

Yes

4. Do you chew more frequently on one side than the other?

Yes

If so, which one:

Left

Right

5. Are your teeth sensitive?

Yes

If so, specify:

To heat

To cold

To sugars

When chewing

6. Do you consume it daily?

Yes

Sweets (candy, chocolate, jam, honey, etc.)

Acidic drinks (fruit juice, etc.)

7. Do you have a gag reflex (feeling of nausea)?

When brushing your teeth?

Yes

When having a dental impression or X-ray taken?

Yes

8. Do you grind your teeth?

Yes

During the day

At night

9. Do you tend to clench your teeth?

Yes

10. Do you have:

Pain in your jaw muscles?

Cracking sounds in your jaw joint (TMJ)?

11. Do you habitually bite or hold objects between your teeth, such as pencils, pipes, nails, or pins?

Yes

I, the undersigned, declare that I have answered this questionnaire truthfully and with the desire to provide information so that I may receive the most appropriate care. In the event of any changes in my health or if I become aware of any new information relating to my health, I undertake to notify the person who asked me to complete this questionnaire without delay.

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