Confidential and Secure Health Questionnaire - Centre dentaire du Vieux Sherbrooke

Confidential and Secure Health Questionnaire

Ordre des dentistes du Québec

Dental records are compiled as part of the care that will be provided: they are protected by law and professional secrecy. They are kept in the office and only the dentist and his or her staff have access to them. The patient also has a right of access and rectification.

Which team do you deal with

Patient information


Birth date

Custodian fees


Dental informations

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

Have you ever had an allergic reaction or ather to the following products:

Autres aspects

COVID-19 Informations

Health status of the patient and any accompanying person in the 14 days prior to the appointment:

Please note that an affirmative answer to any of these questions will require further questioning by your professional before confirming your dental appointment.

Check the corresponding boxes and specify the dates of appearance

Exposure to risks in the 14 days prior to the date of the appointment

1.Close contact is contact with a person who has shared the same living space as you (e.g. in the family) or has had direct contact with you, face to face, within 1 meter and/or for more than 15 minutes, when coughing, sneezing or talking. This may occur in the following situations: flirting, talking with close friends, or with classmates or colleagues, being around someone in a means of transportation for a prolonged period of time, caring for a confirmed case, or handling biological samples from a confirmed case without adequate means of protection.

Consent to communicate with a health professional

List of my generalist doctor(s), specialist doctor(s), pharmacist, other

Patient or guardian signature:

You must sign the questionnaire

Fields marked with an asterisk (*) are required.