Patient Identification (Section A)

Medical/Dental History (Section B)

Patient Identification (Section A)

Email correspondence

Patient's surname

Patient's given name

Sex

Female

Male

Age

Date of birth

Occupation

School

Level

Address

Address and apartment

City

Postal code

Home phone

Mobile phone

Work phone

Extension

Person responsible for fees

Relationship with the patient

Occupation (facultatif)

Do you want a claim form for your insurance?

Yes

You were referred to our clinic by

Reason for consultation

Medical/Dental History (Section B)

Your current dentist's name
Your current dentist's address
Last dental visit

0-6 months

6-12 months

More than 12 months

Number of dental X-rays in the last two years
Have you ever consulted an orthodontist?

Yes

When?
Do you play a musical instrument?

Yes

If so, which instrument?
Have you ever had an accident on your head or face?

Yes

Have you ever had a dental trauma (fracture, blow to teeth, etc.)?

Yes

Have you ever had a head, face, jaw or mouth operation?

Yes

Have you ever had orthodontic treatment?

Yes

Have you ever had teeth extracted for orthodontic reasons?

Yes

Do you have difficulty opening your mouth?

Yes

Does your jaw "crack"?

Yes

Do your gums bleed?

Yes

Do you have sensitive teeth?

Yes

Oral habits

Thumb sucking (finger)

Tongue propulsion

Mouth breathing

Diction problems

Lip biting

Nail biting

Toothache

Tooth grinding

Other

Your family doctor's name
Your family doctor's address

Date of your last medical examination

Are you currently under the care of a doctor?

Yes

If so, why?
Do you take any medication or have you taken any in the last 6 months?

Yes

If so, which medication?
Are you taking the birth control pill?

Yes

Teenagers: At what age did you have your first menstrual period?
Teenagers: At what age did your voice begin to change?
Are you pregnant?

Yes

Do you smoke?

Yes

Have you ever had an allergic reaction to a drug, food, nickel or other substance?

Yes

If so, which substance?
Have you ever been hospitalized?

Yes

If so, why?

Do you suffer or have you suffered from the conditions below? (Section B)

Heart problems

Yes

Rheumatic fever, endocarditis

Yes

Prolonged bleeding

Yes

Anemia

Yes

High blood pressure

Yes

Low blood pressure

Yes

Frequent colds or sinusitis

Yes

Tuberculosis or lung problems

Yes

Asthma

Yes

Removal of tonsils or adenoids

Yes

HIV (seropositive)

Yes

Psychological or emotional problems

Yes

Digestive problems

Yes

Liver problems(hepatitis, cirrhosis)

Yes

Kidney problems

Yes

Venereal disease (STD)

Yes

Diabetes

Yes

Thyroid problems

Yes

Skin diseases

Yes

Eye problems

Yes

Arthritis

Yes

Epilepsy

Yes

Frequent headaches

Yes

Dizziness, fainting

Yes

Earaches

Yes

Hay fever

Yes

Persistent cough

Yes

Mononucleosis

Yes

Radiation therapy for tumor or other

Yes

Other relevant medical or dental information

The Association des Orthodontistes du Québec has published a document on the management of orthodontic treatment in the context of a pandemic in order to help patients with all types of treatment. Do not hesitate to consult it by clicking here.

For any situation or emergency that absolutely requires immediate management (swelling, acute pain, broken major appliance, bleeding), please contact us at 450‑934‑7700 or send a message with photos by e-mail to the following address: clinique@ortholaval.com. The orthodontist will be able to perform a ''Cyber Consultation'' in order to analyze the situation and save you any unnecessary travel.

Monday	7h30	to	16h30
Tuesday	7h30	to	16h30
Wednesday	7h30	to	16h30
Thursday	7h30	to	15h30
Friday *Some Fridays with patients according to school hours. Secretariat at all times.	7h30	to	13h00
Saturday closed
Sunday closed

Medical/dental questionnaire

Patient Identification (Section A)

Medical/Dental History (Section B)

Patient Identification (Section A)

Address

Medical/Dental History (Section B)

Do you suffer or have you suffered from the conditions below? (Section B)

COVID-19 * { fill: #d33 }

Important message in order to serve you better...

COVID-19