23 avenue Victor Hugo 13100 AIX en PROVENCE

+33 4 42 38 99 19

clinicdent@yahoo.fr

Dentistes Aix- Drs Anne PFITZINGER, Christophe COUNAS et Alain COUNAS

Endodontie-Parodontie-Blanchiment - Implants dentaires - Prothèses esthétiques - Facettes - Orthodontie

+33 4 42 38 99 19

Medical questionnaire in English

PROFIL

Name

First name

Date of birth

Profession

Phone

MEDICAL HISTORY – QUESTIONS

Have you had any change in your health this past year ?

Have you been hospitalised in the last five years ?

Who is your general practioner ?

Phone number

HEALTH PROBLEMS OR DISEASE HISTORY

Check present or past diseases.

Other

Have you ever had unusual bleeding during a surgical operation, a tooth extraction or an accident ?

Do you smoke ?

If yes, how many cigarettes a day ?

MEDICAL TREATMENTS

Have you been treated with biphosphonates ?

Are you curently under one or any of these treatment (s)?

Other

ALLERGY

Have you ever had serious allergical reactions ?

Are you allergic to one or any of these following products ? (Check the answer)

Other

Do you have any other diseases or problems to be aware of to provide care under best conditions ? If yes, what are they

FOLLOWING QUESTIONS FOR WOMEN ONLY

Are you pregnant ?

how many months

How many times have been pregnant ?

Do you use the contraceptive pill ?

Are you menauposed ?

DENTAL HISTORY

What is the reason for your visit ? Why are you consulting ?

GUMS

Do you feel you have bad breath ?

Do you have tooth mobility ?

Do your gums bleed after brushing ?

Are you gums painful or sensitive ?

Does the calcus or tartar appear quickly on your teeth ?

TEETH

If you have missing teeth that have been extracted, have they been replaced ?

If yes by :

If no, for what reason ?

Do you have any burning sensations in the mouth ?

JAWS

Do you often have head, neck or ear pain ?

Do you have problems opening your mouth wide ?

Does your jaws crack when you open your mouth ?

Do you clench or grind your teeth ?

DENTAL HYGIENE

What kind of tooth brush do you use :

Do you use floss or inter proximal brushes ?

When was your last cavity treated?

ESTHETICS

When you smile do your teeth have the same color ?

Would you like to have whiter teeth ?

Are you satisfied with the look of your teeth and gums ?

If you could change your smile, what would you like to change ?

OTHER

Do you want to be called for recall visits ?

Did you have any particular problem in previous dental treatments ?

If yes, what are they ?

What is your main concern regarding your teeth ?

Do you have a mutual insurance or complementary insurance ?

What are the day and the hours you prefer for appointments ?

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