{"id":2651,"date":"2020-08-26T05:50:05","date_gmt":"2020-08-26T04:50:05","guid":{"rendered":"https:\/\/retterdentalcare.com\/?page_id=2651"},"modified":"2020-08-26T05:50:05","modified_gmt":"2020-08-26T04:50:05","slug":"infomation-du-patient","status":"publish","type":"page","link":"https:\/\/retterdentalcare.com\/fr\/infomation-du-patient\/","title":{"rendered":"Infomation du patient"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2470-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2470\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/2651#wpcf7-f2470-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2470\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2470-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label> Nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-nom\" \/><\/span> <\/label>\n<\/p>\n<p>Sexe<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sexe\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sexe\" value=\"M\" \/><span class=\"wpcf7-list-item-label\">M<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sexe\" value=\"F\" \/><span class=\"wpcf7-list-item-label\">F<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Date de naissance<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-de-naissance\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-de-naissance\" \/><\/span> <\/label>\n<\/p>\n<p><label> Age<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"age\" \/><\/span> <\/label>\n<\/p>\n<p><label> Adresse<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse\" \/><\/span> <\/label>\n<\/p>\n<p><label> Ville<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ville\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ville\" \/><\/span> <\/label>\n<\/p>\n<p><label> Adresse internet<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse-internet\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse-internet\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Occupation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span> <\/label>\n<\/p>\n<p><label> Tel.: Bur.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-bur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-bur\" \/><\/span> <\/label>\n<\/p>\n<p><label> Ext.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"extension\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"extension\" \/><\/span> <\/label>\n<\/p>\n<p>Meilleur moment pour vous contacter:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"best-time\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">A tout moment<\/span><input type=\"radio\" name=\"best-time\" value=\"A tout moment\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item\"><span class=\"wpcf7-list-item-label\">Jour<\/span><input type=\"radio\" name=\"best-time\" value=\"Jour\" \/><\/span><span class=\"wpcf7-list-item\"><span class=\"wpcf7-list-item-label\">Soir<\/span><input type=\"radio\" name=\"best-time\" value=\"Soir\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">Fin de semaine<\/span><input type=\"radio\" name=\"best-time\" value=\"Fin de semaine\" \/><\/span><\/span><\/span>\n<\/p>\n<p>Est-ce que d'autres membres de votre famille sont patients a notre clinique?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-friends\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Non<\/span><input type=\"radio\" name=\"family-friends\" value=\"Non\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">Oui<\/span><input type=\"radio\" name=\"family-friends\" value=\"Oui\" \/><\/span><\/span><\/span>\n<\/p>\n<p><label> Refere par<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"refere\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"refere\" \/><\/span> <\/label>\n<\/p>\n<p>En cas d'urgence, contactez:\n<\/p>\n<p><label> Nom<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"urgence-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"urgence-nom\" \/><\/span> <\/label>\n<\/p>\n<p><label> Lien<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lien\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lien\" \/><\/span> <\/label>\n<\/p>\n<p><label> Telephone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"urgence-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"urgence-phone\" \/><\/span> <\/label>\n<\/p>\n<p>ASSURANCE DENTAIRE\n<\/p>\n<p><label>Nom de l'assure(e)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-primary\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date de naissance<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-de-naissance-primary\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-de-naissance-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employeur<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"employeur-primary\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employeur-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> Insurance Company<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-compagnie-d-assurance-primary\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance-compagnie-d-assurance-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> No. de groupe ou de police<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"group-policy-primary\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"group-policy-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> No. de certificat ou d'identification<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"certificate-id-primary\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"certificate-id-primary\" \/><\/span> <\/label>\n<\/p>\n<p>ASSURANCE DENTAIRE (ADDITIONNELLE)\n<\/p>\n<p><label>Nom de l'assure(e)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-additional\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-additional\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date de naissance<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-de-naissance-additional\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-de-naissance-additional\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employeur<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"employeur-additional\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employeur-additional\" \/><\/span> <\/label>\n<\/p>\n<p><label> Insurance Company<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-compagnie-d-assurance-additional\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance-compagnie-d-assurance-additional\" \/><\/span> <\/label>\n<\/p>\n<p><label> No. de groupe ou de police<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"group-policy-additional\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"group-policy-additional\" \/><\/span> <\/label>\n<\/p>\n<p><label> No. de certificat ou d'identification<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"certificate-id-additional\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"certificate-id-additional\" \/><\/span> <\/label>\n<\/p>\n<h1>HISTOIRE MEDICALE\n<\/h1>\n<p><label> Medecin de famille<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-doctor\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-doctor\" \/><\/span> <\/label>\n<\/p>\n<p><label> Telephone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telephone-med-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telephone-med-history\" \/><\/span> <\/label>\n<\/p>\n<p><label> Poste<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"extension-med-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"extension-med-history\" \/><\/span> <\/label>\n<\/p>\n<p><label> Poids<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"weight\" \/><\/span> <\/label>\n<\/p>\n<p><label> Taille<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"height\" \/><\/span> <\/label>\n<\/p>\n<p>Etes-vous actuellement sous les soins d'un medecin?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"under-doctor-care\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"under-doctor-care\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"under-doctor-care\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Prenez-vous (presentement) des medicaments ou en avez-vous pris au cours des 6 derniers mois?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drug-or-medication\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"drug-or-medication\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"drug-or-medication\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Si oui, lesquels:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"if-so-which\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"if-so-which\" \/><\/span> <\/label>\n<\/p>\n<p>Prenez-vous des produits naturels (homeopathie)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"homeopathic-products\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"homeopathic-products\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"homeopathic-products\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Si oui, lesquels:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"if-so-which-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"if-so-which-2\" \/><\/span> <\/label>\n<\/p>\n<p>Avez-vous ete hospitalise et\/ou subi des interventions chirurgicales autres que dentaires?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"surgical-intervention\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"surgical-intervention\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"surgical-intervention\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous ete diagnostique ou traite pour un cancer?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"diagnosed-cancer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"diagnosed-cancer\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"diagnosed-cancer\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous eu des problemes ou maladies cardiaques; infarctus, angine, souffle ou problemes valvulaires?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"heart-transplant\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"heart-transplant\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"heart-transplant\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Est-ce que vous fumez ou machez du tabac?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"smoke\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"smoke\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"smoke\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous eu des maladies\/traitements qui peuvent affecter votre systeme immunitaire (SIDA, Chimio...)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"immune-system\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"immune-system\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"immune-system\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><strong>Avez-vous souffert ou souffrez-vous de:<\/strong>\n<\/p>\n<p>Tension arterielle (Basse\/Haute)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"blood-pressure\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blood-pressure\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blood-pressure\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Troubles digestifs<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"digestive\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"digestive\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"digestive\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Diabete<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"diabetes\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"diabetes\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Problemes oculaires (yeux)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"eye-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"eye-problems\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"eye-problems\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Asthme<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"asthma\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"asthma\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Rhumes frequents ou sinusite<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"colds-sinusitis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"colds-sinusitis\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"colds-sinusitis\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Troubles du rein<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kidney-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"kidney-disease\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"kidney-disease\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Saignement prolonges<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prolonged-bleeding\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"prolonged-bleeding\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"prolonged-bleeding\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Problemes pulmonaires<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lung-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"lung-disease\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"lung-disease\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Valve mitrale prolapsus<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mitral-valve\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"mitral-valve\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"mitral-valve\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Stimulateur cardiaque<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pacemaker\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"pacemaker\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"pacemaker\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Maladies transmises sexuellement<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"venereal-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"venereal-disease\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"venereal-disease\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Etourdissements\/Evanouissements<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dizzy-fainting\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"dizzy-fainting\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"dizzy-fainting\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Epilepsie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"epilepsy\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"epilepsy\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Troubles nerveux<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nervous-disorder\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"nervous-disorder\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"nervous-disorder\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Ulceres d'estomac<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stomach-ulcers\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"stomach-ulcers\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"stomach-ulcers\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Rhume des foins<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hay-fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"hay-fever\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"hay-fever\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Maux d'oreilles<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"earaches\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"earaches\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"earaches\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Maladies de la peau<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"skin-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"skin-disease\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"skin-disease\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Maux de tetes frequents<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"freq-headaches\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"freq-headaches\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"freq-headaches\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Dependance Alcoolique\/Toxicomanie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drug-alcohol\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"drug-alcohol\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"drug-alcohol\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Osteoporose<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"osteoporosis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"osteoporosis\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"osteoporosis\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Fievre rhumatismale<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rheumatic\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rheumatic\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rheumatic\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Problemes de foie (Hepatite)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"liver-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"liver-disease\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"liver-disease\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Arthrite<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"arthritis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"arthritis\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"arthritis\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Problemes de dos<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"back-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"back-problems\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"back-problems\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Prothese articulaires\/Implants<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"artificial-joints\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"artificial-joints\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"artificial-joints\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>SIDA \/ Seropositif<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"aids-hiv\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"aids-hiv\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"aids-hiv\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Troubles thyroidiens<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"thyroid-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"thyroid-problems\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"thyroid-problems\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Anemie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"anemia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"anemia\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"anemia\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Tuberculose<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tuberculosis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"tuberculosis\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"tuberculosis\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Leucemie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"leukemia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"leukemia\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"leukemia\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Autres<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-med-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-med-history\" \/><\/span> <\/label>\n<\/p>\n<p><strong>Avez-vous deja fait une reaction aux produits suivants:<\/strong>\n<\/p>\n<p>Aliments Specifiques<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-foods\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-foods\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-foods\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Antibiotiques (Penicilline)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-antibiotics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-antibiotics\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-antibiotics\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Iode<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-iodine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-iodine\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-iodine\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Latex (Caoutchouc)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-latex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-latex\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-latex\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Sedatifs<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-sedatives\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-sedatives\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-sedatives\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Sulfamides<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-sulfa-drugs\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-sulfa-drugs\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-sulfa-drugs\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Aspirine\/Codeine<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-aspirin-codeine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-aspirin-codeine\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-aspirin-codeine\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Anesthesie Locale<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-anesthetics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-anesthetics\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-anesthetics\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Metaux<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-metals\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-metals\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-metals\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Saveurs Artificielles<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergy-flavours\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergy-flavours\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergy-flavours\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Autres<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-allergy\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-allergy\" \/><\/span> <\/label>\n<\/p>\n<p>Avez-vous deja ete avise de ne pas donner de sang?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"told-not-donate-blood\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"told-not-donate-blood\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"told-not-donate-blood\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Prenez-vous des medicaments pour l'osteoporose ou le cancer des os (Actonel, Fosamax, etc.)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drugs-for-osteoporosis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"drugs-for-osteoporosis\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"drugs-for-osteoporosis\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><strong>Femmes Seulement:<\/strong>\n<\/p>\n<p>Etes-vous enceinte ou pensez-vous l'etre?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pregnant[]\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pregnant[]\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Allaitez-vous en ce moment?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant-nursing\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pregnant-nursing[]\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pregnant-nursing[]\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Prenez-vous des contraceptifs oraux?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"taking-contraceptives\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"taking-contraceptives[]\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"taking-contraceptives[]\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<h1>HISTOIRE DENTAIRE\n<\/h1>\n<p>Derniere visite:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-visit\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"last-visit\" value=\"0-6 mois\" \/><span class=\"wpcf7-list-item-label\">0-6 mois<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"last-visit\" value=\"6-12 mois\" \/><span class=\"wpcf7-list-item-label\">6-12 mois<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"last-visit\" value=\"&gt; + de 12 mois\" \/><span class=\"wpcf7-list-item-label\">&gt; + de 12 mois<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Dernieres radiographies dentaires prises?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-dental-xray\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-dental-xray\" \/><\/span> <\/label>\n<\/p>\n<p><label> A quelle frequence brossez-vous les dents?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"often-brushing\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"often-brushing\" \/><\/span> <\/label>\n<\/p>\n<p><label> A quelle frequence utilisez-vous la soie dentaire?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"often-floss\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"often-floss\" \/><\/span> <\/label>\n<\/p>\n<p>Visitez-vous regulierement votre dentiste?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"regularity\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"regularity\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"regularity\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous des douleurs au niveau des dents?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"teeth-ache\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"teeth-ache\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"teeth-ache\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Vos gencives saignent-elles quand vous les brossez?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bleeding-gums\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bleeding-gums\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bleeding-gums\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous de la douleur quand vous mastiquez?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chew-pain\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"chew-pain\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"chew-pain\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Etes-vous satisfait de votre haleine?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bad-breathe\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bad-breathe\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bad-breathe\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous deja eu des belssures a la machoire?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"blows-jaw\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blows-jaw\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blows-jaw\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vou deja eu des implants dentaires?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"implants-jaw\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"implants-jaw\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"implants-jaw\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous deja eu a prendre des antibiotiques avant une chirurgie dentaire?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"antibiotics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"antibiotics\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"antibiotics\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Etes-vous suivi par un dentiste specialiste?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-follow-up\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"dental-follow-up\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"dental-follow-up\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Etes-vous craintif face aux traitements dentaires?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nervous\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"nervous\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"nervous\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<h1>CONSENTEMENT ECLAIRE\n<\/h1>\n<p>Je, soussigne(e), declare avoir lu, compris, m'etre renseigne(e) et avoir repondu au questionnaire medico-dentaire ci-dessus au meilleur de ma connaissance. <strong>Je m'engage, par la presente, a vous aviser de tout changement de mon etat de sante.<\/strong>\n<\/p>\n<p>J'autorise la constitution d emon dossier dentaire , son suivi, ainsi que mon inscription sur la liste de rappel du (des) dentiste(s) traitant(s).\n<\/p>\n<p>On m'a informe(e) que mon dossier sera conserve au cabinet en tout temps et que seul(s) le (les) dentiste(s) et son (leur) personnel auxiliaire y aura (auront) acces.\n<\/p>\n<p>On m'a aussi informe(e) de mon droit de consulter mon dossier, d'y demander une rectification et de me retirer de la liste de rappel.\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"informed-content\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"informed-content\" value=\"Oui\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"informed-content\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SUBMIT\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2651","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Infomation du patient - Retter Dental Care<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/retterdentalcare.com\/patient-information-form\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Infomation du patient - Retter Dental Care\" \/>\n<meta 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