info@maxillomauricie.com
819 378-4353
Zygoma Zaga Centers

MEDICAL FORM

1 Step 1

Please answer all questions

Have you ever taken the following medications :
Are you actually taking other medication or natural products ?
In the eventuallity of a surgery in the opereting room at the hospital, is there any question/preoccupation you would like to discuss with the anestheologist prior to the surgery ?

Have you been or are you actually treated for one or many of these conditions :

Cardiologic problem :
Bleeding disorder :
Infection problem :
Endocrinologic problem :
Hepatologic/digestive problem :
Neurologic problem :
Oncologic problem :
Pulmonary problem :
Renal problem :
Other problems
Are you allergic to :

Are you using :

Habits
RegularlyOccasionnelyNever
Tabacco
Alcohol
Drugs
Do you fear dental treatment ?
Anxiety questions
Not anxious at all (1)Slightly anxious (2)Fairly anxious (3)Very anxious (4)Extremely anxious (5)
If you were going to the dentist for treatment tomorrow, how would you feel?
If you were sitting in the waiting room waiting for your treatment, how would you feel?
If you were about to have a filling done, how would you feel?
If you were about to have a dental cleaning, how would you feel?
If you were about to receive a local anesthetic injection to numb a tooth, how would you feel?
What is your score from the previous question?Add up the points from each of your answers to the previous question to get your total score.
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