{"id":929,"date":"2020-10-27T15:36:23","date_gmt":"2020-10-27T14:36:23","guid":{"rendered":"https:\/\/dentiste-mbemba.be\/?page_id=929"},"modified":"2020-10-28T13:25:07","modified_gmt":"2020-10-28T12:25:07","slug":"historique-medical-dentaire-adulte","status":"publish","type":"page","link":"https:\/\/dentiste-mbemba.be\/index.php\/historique-medical-dentaire-adulte\/","title":{"rendered":"Historique m\u00e9dical et dentaire ADULTE"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"929\" class=\"elementor elementor-929\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a608511 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a608511\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-00e8591\" data-id=\"00e8591\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a8cb21a elementor-widget elementor-widget-heading\" data-id=\"a8cb21a\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Historique m\u00e9dical & dentaire - ADULTE<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d317d01 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"d317d01\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-751eb9a elementor-widget elementor-widget-spacer\" data-id=\"751eb9a\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-264e568 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"264e568\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ce081a9\" data-id=\"ce081a9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-46586b5 elementor-widget elementor-widget-shortcode\" data-id=\"46586b5\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-933\"><form id=\"wpforms-form-933\" class=\"wpforms-validate wpforms-form\" data-formid=\"933\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/929\" data-token=\"007f9b99cf969a91ea488e6026b7428d\" data-token-time=\"1777983389\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-933-field_3-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"3\"><label class=\"wpforms-field-label wpforms-label-hide\">Genre<\/label><ul id=\"wpforms-933-field_3\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_3_1\" name=\"wpforms[fields][3]\" value=\"Mme\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_3_1\">Mme<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_3_2\" name=\"wpforms[fields][3]\" value=\"Melle\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_3_2\">Melle<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_3_3\" name=\"wpforms[fields][3]\" value=\"Mr\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_3_3\">Mr<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_0\">Identit\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-933-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" placeholder=\"Pr\u00e9nom\" required><label for=\"wpforms-933-field_0\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-933-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" placeholder=\"Nom\" required><label for=\"wpforms-933-field_0-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-933-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_7\">Date de naissance <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-933-field_7\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\/99\/9999\" name=\"wpforms[fields][7]\" placeholder=\"JJ\/MM\/AAAA\" required><\/div><div id=\"wpforms-933-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_8\">NISS <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-933-field_8\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99.99.99-999-99\" name=\"wpforms[fields][8]\" placeholder=\"xx.xx.xx-xxx-xx\" required><div class=\"wpforms-field-description\">N\u00b0 Registre national<\/div><\/div><div id=\"wpforms-933-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_9\">Profession<\/label><input type=\"text\" id=\"wpforms-933-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-933-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_10\">Nom de votre m\u00e9decin traitant<\/label><input type=\"text\" id=\"wpforms-933-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-933-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_11\">A quand remonte votre dernier examen m\u00e9dical <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-933-field_11\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\/99\/9999\" name=\"wpforms[fields][11]\" placeholder=\"JJ\/MM\/AAAA\" required><\/div><div id=\"wpforms-933-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Avez -vous connu des changements dans votre \u00e9tat de sant\u00e9 depuis un an ?<\/label><ul id=\"wpforms-933-field_12\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_12_1\" name=\"wpforms[fields][12]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_12_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_12_2\" name=\"wpforms[fields][12]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_12_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Merci de cocher chacune des maladies ou chacun des probl\u00e8mes suivants que vous avez pu avoir par le pass\u00e9 ou que vous avez actuellement<\/label><ul id=\"wpforms-933-field_13\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Antid\u00e9presseurs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_1\">Antid\u00e9presseurs<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_4\" name=\"wpforms[fields][13][]\" value=\"Asthme\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_4\">Asthme<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_5\" name=\"wpforms[fields][13][]\" value=\"Chirurgie esth\u00e9tique\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_5\">Chirurgie esth\u00e9tique<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_6\" name=\"wpforms[fields][13][]\" value=\"D\u00e9sordres hormonaux\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_6\">D\u00e9sordres hormonaux<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_7\" name=\"wpforms[fields][13][]\" value=\"Diab\u00e8te\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_7\">Diab\u00e8te<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_8\" name=\"wpforms[fields][13][]\" value=\"Glaucome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_8\">Glaucome<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_9\" name=\"wpforms[fields][13][]\" value=\"H\u00e9patite A, B ou C\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_9\">H\u00e9patite A, B ou C<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_10\" name=\"wpforms[fields][13][]\" value=\"L\u00e9sions cardiaques cong\u00e9nitales\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_10\">L\u00e9sions cardiaques cong\u00e9nitales<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_11\" name=\"wpforms[fields][13][]\" value=\"Ulc\u00e8res \u00e0 l\u2019estomac\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_11\">Ulc\u00e8res \u00e0 l\u2019estomac<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_12\" name=\"wpforms[fields][13][]\" value=\"Maladie du foie\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_12\">Maladie du foie<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_13\" name=\"wpforms[fields][13][]\" value=\"Maladies cardiaques\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_13\">Maladies cardiaques<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_14\" name=\"wpforms[fields][13][]\" value=\"Maladie du sang\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_14\">Maladie du sang<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_15\" name=\"wpforms[fields][13][]\" value=\"Maladies v\u00e9n\u00e9riennes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_15\">Maladies v\u00e9n\u00e9riennes<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_16\" name=\"wpforms[fields][13][]\" value=\"\u0152d\u00e8mes (gonflements)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_16\">\u0152d\u00e8mes (gonflements)<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_17\" name=\"wpforms[fields][13][]\" value=\"Pacemaker\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_17\">Pacemaker<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_19\" name=\"wpforms[fields][13][]\" value=\"Pertes de connaissance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_19\">Pertes de connaissance<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_18\" name=\"wpforms[fields][13][]\" value=\"Probl\u00e8mes circulatoires\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_18\">Probl\u00e8mes circulatoires<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_21\" name=\"wpforms[fields][13][]\" value=\"Probl\u00e8mes nerveux\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_21\">Probl\u00e8mes nerveux<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_20\" name=\"wpforms[fields][13][]\" value=\"Proth\u00e8ses (autres que dentaires)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_20\">Proth\u00e8ses (autres que dentaires)<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_22\" name=\"wpforms[fields][13][]\" value=\"Rhumatisme Articulaire Aigu\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_22\">Rhumatisme Articulaire Aigu<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_24\" name=\"wpforms[fields][13][]\" value=\"S\u00e9ropositivit\u00e9 HIV\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_24\">S\u00e9ropositivit\u00e9 HIV<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_23\" name=\"wpforms[fields][13][]\" value=\"Sinusites r\u00e9p\u00e9t\u00e9es\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_23\">Sinusites r\u00e9p\u00e9t\u00e9es<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_25\" name=\"wpforms[fields][13][]\" value=\"Syncopes, vertiges\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_25\">Syncopes, vertiges<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_26\" name=\"wpforms[fields][13][]\" value=\"Thyro\u00efde\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_26\">Thyro\u00efde<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_27\" name=\"wpforms[fields][13][]\" value=\"Troubles des reins\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_27\">Troubles des reins<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_28\" name=\"wpforms[fields][13][]\" value=\"Tumeur maligne\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_28\">Tumeur maligne<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_13_29\" name=\"wpforms[fields][13][]\" value=\"Autres maladies (\u00e0 mentionner ci-dessous)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_13_29\">Autres maladies (\u00e0 mentionner ci-dessous)<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Les r\u00e9ponses seront compl\u00e9t\u00e9es lors de l'entretien avec le Dentiste<\/div><\/div><div id=\"wpforms-933-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_14\">Autre maladies \u00e9ventuelles ?<\/label><input type=\"text\" id=\"wpforms-933-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-933-field_15-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"15\"><label class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu un saignement anormal au cours d\u2019une intervention ou d\u2019un accident ?<\/label><ul id=\"wpforms-933-field_15\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_15_1\" name=\"wpforms[fields][15]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_15_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_15_2\" name=\"wpforms[fields][15]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_15_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_16-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"16\"><label class=\"wpforms-field-label\">Avez-vous subi un traitement par radiations ? <\/label><ul id=\"wpforms-933-field_16\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_16_1\" name=\"wpforms[fields][16]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_16_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_16_2\" name=\"wpforms[fields][16]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_16_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_17-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Prenez-vous des m\u00e9dicaments en ce moment ?<\/label><ul id=\"wpforms-933-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_17_1\" name=\"wpforms[fields][17]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_17_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_17_2\" name=\"wpforms[fields][17]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_17_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_18-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"18\"><label class=\"wpforms-field-label\">Si vous prenez des m\u00e9dicament, lesquels :<\/label><ul id=\"wpforms-933-field_18\"><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_29\" name=\"wpforms[fields][18][]\" value=\"Antibiotiques\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_29\">Antibiotiques<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_30\" name=\"wpforms[fields][18][]\" value=\"Antihistaminique\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_30\">Antihistaminique<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_32\" name=\"wpforms[fields][18][]\" value=\"Aspirine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_32\">Aspirine<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_31\" name=\"wpforms[fields][18][]\" value=\"Cortisone\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_31\">Cortisone<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_33\" name=\"wpforms[fields][18][]\" value=\"Insuline\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_33\">Insuline<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_35\" name=\"wpforms[fields][18][]\" value=\"Traitement pour la tension art\u00e9rielle\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_35\">Traitement pour la tension art\u00e9rielle<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_34\" name=\"wpforms[fields][18][]\" value=\"Tranquillisant\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_34\">Tranquillisant<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_18_36\" name=\"wpforms[fields][18][]\" value=\"Autres (\u00e0 mentionner ci-dessous)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_18_36\">Autres (\u00e0 mentionner ci-dessous)<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_19\">Autre m\u00e9dicaments \u00e9ventuels ?<\/label><input type=\"text\" id=\"wpforms-933-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-933-field_20-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"20\"><label class=\"wpforms-field-label\">\u00cates-vous allergique \u00e0 certains produits ou m\u00e9dicaments ?<\/label><ul id=\"wpforms-933-field_20\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_20_1\" name=\"wpforms[fields][20]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_20_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_20_2\" name=\"wpforms[fields][20]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_20_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_21-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"21\"><label class=\"wpforms-field-label\">Si vous \u00eates allergique \u00e0 certains produits ou m\u00e9dicaments, lesquels :<\/label><ul id=\"wpforms-933-field_21\"><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_36\" name=\"wpforms[fields][21][]\" value=\"Anesth\u00e9sique local chez le Dentiste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_36\">Anesth\u00e9sique local chez le Dentiste<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_37\" name=\"wpforms[fields][21][]\" value=\"Antibiotique\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_37\">Antibiotique<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_38\" name=\"wpforms[fields][21][]\" value=\"Anti-inflammatoire ou aspirine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_38\">Anti-inflammatoire ou aspirine<\/label><\/li><li class=\"choice-42 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_42\" name=\"wpforms[fields][21][]\" value=\"Barbituriques\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_42\">Barbituriques<\/label><\/li><li class=\"choice-43 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_43\" name=\"wpforms[fields][21][]\" value=\"Cod\u00e9ine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_43\">Cod\u00e9ine<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_39\" name=\"wpforms[fields][21][]\" value=\"Iode et produits d\u00e9riv\u00e9s\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_39\">Iode et produits d\u00e9riv\u00e9s<\/label><\/li><li class=\"choice-41 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_41\" name=\"wpforms[fields][21][]\" value=\"Latex\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_41\">Latex<\/label><\/li><li class=\"choice-40 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_40\" name=\"wpforms[fields][21][]\" value=\"M\u00e9tal\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_40\">M\u00e9tal<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_21_44\" name=\"wpforms[fields][21][]\" value=\"Neuroleptique ou somnif\u00e8re\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_21_44\">Neuroleptique ou somnif\u00e8re<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"22\"><label class=\"wpforms-field-label\">\u00cates-vous fumeur ? <\/label><ul id=\"wpforms-933-field_22\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_22_1\" name=\"wpforms[fields][22]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_22_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_22_2\" name=\"wpforms[fields][22]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_22_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_23\">Si oui, nombre de cigarettes \/ jour :<\/label><input type=\"text\" id=\"wpforms-933-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-933-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"24\"><label class=\"wpforms-field-label\">Madame\/Mademoiselle, \u00eates-vous enceinte ?<\/label><ul id=\"wpforms-933-field_24\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_24_1\" name=\"wpforms[fields][24]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_24_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_24_2\" name=\"wpforms[fields][24]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_24_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_25\">Si oui, de combien de mois :<\/label><input type=\"text\" id=\"wpforms-933-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-933-field_26-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"26\"><label class=\"wpforms-field-label\">Prenez-vous actuellement la pilule ?<\/label><ul id=\"wpforms-933-field_26\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_26_1\" name=\"wpforms[fields][26]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_26_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_26_2\" name=\"wpforms[fields][26]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_26_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_27-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"27\"><label class=\"wpforms-field-label\">Prenez-vous un traitement contre l\u2019ost\u00e9oporose ou une autre maladie osseuse ?<\/label><ul id=\"wpforms-933-field_27\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_27_1\" name=\"wpforms[fields][27]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_27_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_27_2\" name=\"wpforms[fields][27]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_27_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_28-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Si oui, quel type de m\u00e9dicaments prenez-vous ?<\/label><ul id=\"wpforms-933-field_28\"><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_28_47\" name=\"wpforms[fields][28][]\" value=\"Biphosphonates\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_28_47\">Biphosphonates<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_28_44\" name=\"wpforms[fields][28][]\" value=\"Hormones\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_28_44\">Hormones<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_28_45\" name=\"wpforms[fields][28][]\" value=\"\u0152strog\u00e8nes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_28_45\">\u0152strog\u00e8nes<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_29-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_29\">Merci de pr\u00e9ciser toute autre maladie ou tout autre probl\u00e8me non indiqu\u00e9 dans la liste ci-dessus qui pourrait nous aider \u00e0 vous soigner dans les meilleures conditions :<\/label><textarea id=\"wpforms-933-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><\/textarea><\/div><div id=\"wpforms-933-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_30\">\u00c0 quand remonte votre dernier examen dentaire ? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-933-field_30\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\/99\/9999\" name=\"wpforms[fields][30]\" placeholder=\"JJ\/MM\/AAAA\" required><\/div><div id=\"wpforms-933-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_31\">Quel est le motif de votre consultation ?<\/label><input type=\"text\" id=\"wpforms-933-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-933-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_32\">Lors de vos pr\u00e9c\u00e9dentes visites chez le dentiste avez-vous rencontr\u00e9 des difficult\u00e9s particuli\u00e8res ? Si oui, lesquelles ?<\/label><input type=\"text\" id=\"wpforms-933-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-933-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"33\"><label class=\"wpforms-field-label\">GENCIVES \/\/ Avez-vous remarqu\u00e9 que vos dents se sont \u00e9cart\u00e9es depuis quelque temps ?<\/label><ul id=\"wpforms-933-field_33\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_33_1\" name=\"wpforms[fields][33]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_33_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_33_2\" name=\"wpforms[fields][33]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_33_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_34-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"34\"><label class=\"wpforms-field-label\">GENCIVES \/\/ Vos gencives saignent-elles apr\u00e8s le brossage, voire spontan\u00e9ment ?<\/label><ul id=\"wpforms-933-field_34\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_34_1\" name=\"wpforms[fields][34]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_34_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_34_2\" name=\"wpforms[fields][34]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_34_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"35\"><label class=\"wpforms-field-label\">GENCIVES \/\/ Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 trait\u00e9(e) pour les gencives ?<\/label><ul id=\"wpforms-933-field_35\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_35_1\" name=\"wpforms[fields][35]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_35_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_35_2\" name=\"wpforms[fields][35]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_35_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_36-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Si oui, par quel traitement ?<\/label><ul id=\"wpforms-933-field_36\"><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_36_47\" name=\"wpforms[fields][36][]\" value=\"Chirurgie\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_36_47\">Chirurgie<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_36_44\" name=\"wpforms[fields][36][]\" value=\"D\u00e9tartrage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_36_44\">D\u00e9tartrage<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_36_45\" name=\"wpforms[fields][36][]\" value=\"M\u00e9dicaments\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_36_45\">M\u00e9dicaments<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_37-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"37\"><label class=\"wpforms-field-label\">DENTS \/\/ Avez-vous port\u00e9 un appareil ou des bagues pour redresser vos dents ?<\/label><ul id=\"wpforms-933-field_37\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_37_1\" name=\"wpforms[fields][37]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_37_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_37_2\" name=\"wpforms[fields][37]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_37_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_38-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"38\"><label class=\"wpforms-field-label\">DENTS \/\/ Avez-vous des dents extraites ?<\/label><ul id=\"wpforms-933-field_38\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_38_1\" name=\"wpforms[fields][38]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_38_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_38_2\" name=\"wpforms[fields][38]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_38_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"39\"><label class=\"wpforms-field-label\">Si oui, pour quelles raisons ont-elles \u00e9t\u00e9 extraites ?<\/label><ul id=\"wpforms-933-field_39\"><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_39_47\" name=\"wpforms[fields][39][]\" value=\"Caries\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_39_47\">Caries<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_39_44\" name=\"wpforms[fields][39][]\" value=\"D\u00e9chaussement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_39_44\">D\u00e9chaussement<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_39_45\" name=\"wpforms[fields][39][]\" value=\"Dent incluse\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_39_45\">Dent incluse<\/label><\/li><li class=\"choice-48 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_39_48\" name=\"wpforms[fields][39][]\" value=\"Infection ou abc\u00e8s\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_39_48\">Infection ou abc\u00e8s<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_40-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"40\"><label class=\"wpforms-field-label\">DENTS \/\/ Les dents extraites ont-elles \u00e9t\u00e9 remplac\u00e9es ?<\/label><ul id=\"wpforms-933-field_40\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_40_1\" name=\"wpforms[fields][40]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_40_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_40_2\" name=\"wpforms[fields][40]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_40_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Si oui, par quoi ont-elles \u00e9t\u00e9 remplac\u00e9es ?<\/label><ul id=\"wpforms-933-field_41\"><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_41_47\" name=\"wpforms[fields][41][]\" value=\"un appareil mobile\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_41_47\">un appareil mobile<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_41_44\" name=\"wpforms[fields][41][]\" value=\"un bridge fixe\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_41_44\">un bridge fixe<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_41_45\" name=\"wpforms[fields][41][]\" value=\"un implant\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_41_45\">un implant<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_42\">Si non, pour quelle raison n&#039;ont-elles pas \u00e9t\u00e9 remplac\u00e9es ?<\/label><input type=\"text\" id=\"wpforms-933-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/div><div id=\"wpforms-933-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_43\">DENTS \/\/ Si vous portez actuellement des proth\u00e8ses, comment vous sentez-vous avec ?<\/label><input type=\"text\" id=\"wpforms-933-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" ><\/div><div id=\"wpforms-933-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"44\"><label class=\"wpforms-field-label\">DENTS \/\/ Avez-vous des dents sensibles ?<\/label><ul id=\"wpforms-933-field_44\"><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_44_47\" name=\"wpforms[fields][44][]\" value=\"au chaud\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_44_47\">au chaud<\/label><\/li><li class=\"choice-49 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_44_49\" name=\"wpforms[fields][44][]\" value=\"au froid\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_44_49\">au froid<\/label><\/li><li class=\"choice-50 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_44_50\" name=\"wpforms[fields][44][]\" value=\"au sucre\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_44_50\">au sucre<\/label><\/li><li class=\"choice-51 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_44_51\" name=\"wpforms[fields][44][]\" value=\"aux acides\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_44_51\">aux acides<\/label><\/li><li class=\"choice-52 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_44_52\" name=\"wpforms[fields][44][]\" value=\"\u00e0 la mastication\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_44_52\">\u00e0 la mastication<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_45\">DENTS \/\/ Actuellement, quelle est votre pr\u00e9occupation principale concernant vos dents ?<\/label><input type=\"text\" id=\"wpforms-933-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" ><\/div><div id=\"wpforms-933-field_46-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"46\"><label class=\"wpforms-field-label\">M\u00c2CHOIRES \/\/ Serrez-vous ou grincez-vous des dents ?<\/label><ul id=\"wpforms-933-field_46\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_46_1\" name=\"wpforms[fields][46]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_46_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_46_2\" name=\"wpforms[fields][46]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_46_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_47-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"47\"><label class=\"wpforms-field-label\">M\u00c2CHOIRES \/\/ Avez-vous remarqu\u00e9 des craquements, des claquements ou une douleur \u00e0 l\u2019ouverture de la m\u00e2choire ?<\/label><ul id=\"wpforms-933-field_47\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_47_1\" name=\"wpforms[fields][47]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_47_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_47_2\" name=\"wpforms[fields][47]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_47_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_48-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"48\"><label class=\"wpforms-field-label\">M\u00c2CHOIRES \/\/ Avez-vous des difficult\u00e9s \u00e0 avaler, \u00e0 m\u00e2cher ou ne m\u00e2chez-vous fr\u00e9quemment que d\u2019un seul c\u00f4t\u00e9 ?<\/label><ul id=\"wpforms-933-field_48\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_48_1\" name=\"wpforms[fields][48]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_48_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_48_2\" name=\"wpforms[fields][48]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_48_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_49-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"49\"><label class=\"wpforms-field-label\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ Avez-vous (ou avez-vous eu par le pass\u00e9) l\u2019une des habitudes suivantes ?<\/label><ul id=\"wpforms-933-field_49\"><li class=\"choice-53 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_53\" name=\"wpforms[fields][49][]\" value=\"Croquer des cacahu\u00e8tes ou des gla\u00e7ons\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_53\">Croquer des cacahu\u00e8tes ou des gla\u00e7ons<\/label><\/li><li class=\"choice-56 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_56\" name=\"wpforms[fields][49][]\" value=\"Jouer d\u2019un instrument musical \u00e0 vent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_56\">Jouer d\u2019un instrument musical \u00e0 vent<\/label><\/li><li class=\"choice-54 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_54\" name=\"wpforms[fields][49][]\" value=\"M\u00e2cher un crayon, vos lunettes ou un stylo\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_54\">M\u00e2cher un crayon, vos lunettes ou un stylo<\/label><\/li><li class=\"choice-57 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_57\" name=\"wpforms[fields][49][]\" value=\"Se mordre la langue, la l\u00e8vre ou la joue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_57\">Se mordre la langue, la l\u00e8vre ou la joue<\/label><\/li><li class=\"choice-55 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_55\" name=\"wpforms[fields][49][]\" value=\"Se ronger les ongles\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_55\">Se ronger les ongles<\/label><\/li><li class=\"choice-52 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_49_52\" name=\"wpforms[fields][49][]\" value=\"Succion du pouce\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_49_52\">Succion du pouce<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"50\"><label class=\"wpforms-field-label\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ Quel type de brosse \u00e0 dents utilisez-vous ?<\/label><ul id=\"wpforms-933-field_50\"><li class=\"choice-52 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_50_52\" name=\"wpforms[fields][50][]\" value=\"DURE\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_50_52\">DURE<\/label><\/li><li class=\"choice-54 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_50_54\" name=\"wpforms[fields][50][]\" value=\"MOYENNE\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_50_54\">MOYENNE<\/label><\/li><li class=\"choice-53 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_50_53\" name=\"wpforms[fields][50][]\" value=\"SOUPLE\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_50_53\">SOUPLE<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"51\"><label class=\"wpforms-field-label\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ Quand vous brossez-vous les dents ?<\/label><ul id=\"wpforms-933-field_51\"><li class=\"choice-52 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_51_52\" name=\"wpforms[fields][51][]\" value=\"MATIN\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_51_52\">MATIN<\/label><\/li><li class=\"choice-54 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_51_54\" name=\"wpforms[fields][51][]\" value=\"MIDI\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_51_54\">MIDI<\/label><\/li><li class=\"choice-53 depth-1\"><input type=\"checkbox\" id=\"wpforms-933-field_51_53\" name=\"wpforms[fields][51][]\" value=\"SOIR\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_51_53\">SOIR<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_52\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ \u00c0 quel rythme changez-vous de brosse \u00e0 dents ?<\/label><input type=\"text\" id=\"wpforms-933-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" ><\/div><div id=\"wpforms-933-field_53-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"53\"><label class=\"wpforms-field-label\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ Utilisez-vous du fil dentaire ou des brossettes interdentaires ?<\/label><ul id=\"wpforms-933-field_53\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_53_1\" name=\"wpforms[fields][53]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_53_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_53_2\" name=\"wpforms[fields][53]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_53_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"54\"><label class=\"wpforms-field-label\">HABITUDES ET HYGI\u00c8NE DENTAIRE \/\/ Avez-vous l\u2019impression d\u2019avoir une mauvaise haleine ou un mauvais go\u00fbt dans la bouche ?<\/label><ul id=\"wpforms-933-field_54\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_54_1\" name=\"wpforms[fields][54]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_54_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_54_2\" name=\"wpforms[fields][54]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_54_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_54_3\" name=\"wpforms[fields][54]\" value=\"Parfois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_54_3\">Parfois<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_55-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"55\"><label class=\"wpforms-field-label\">SOURIRE \/\/ Dans un large sourire, vos dents sont-elles toutes de la m\u00eame couleur ?<\/label><ul id=\"wpforms-933-field_55\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_55_1\" name=\"wpforms[fields][55]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_55_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_55_2\" name=\"wpforms[fields][55]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_55_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"56\"><label class=\"wpforms-field-label\">SOURIRE \/\/ Aimeriez-vous avoir des dents plus blanches ? <\/label><ul id=\"wpforms-933-field_56\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_56_1\" name=\"wpforms[fields][56]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_56_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_56_2\" name=\"wpforms[fields][56]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_56_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_57-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"57\"><label class=\"wpforms-field-label\">SOURIRE \/\/ \u00cates-vous satisfait(e) de l\u2019apparence de vos dents et de vos gencives ?<\/label><ul id=\"wpforms-933-field_57\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_57_1\" name=\"wpforms[fields][57]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_57_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_57_2\" name=\"wpforms[fields][57]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_57_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_58-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"58\"><label class=\"wpforms-field-label\">SOURIRE \/\/ Mettez-vous la main devant la bouche lorsque vous riez ou souriez ?<\/label><ul id=\"wpforms-933-field_58\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_58_1\" name=\"wpforms[fields][58]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_58_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-933-field_58_2\" name=\"wpforms[fields][58]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-933-field_58_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-933-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_59\">SOURIRE \/\/ Si vous aviez la possibilit\u00e9 de changer votre sourire, qu\u2019aimeriez-vous changer ?<\/label><input type=\"text\" id=\"wpforms-933-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-933-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_60\">\u00cates-vous \u00e0 l\u2019aise avec les soins dentaires ?<\/label><input type=\"text\" id=\"wpforms-933-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" ><\/div><div id=\"wpforms-933-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_61\">COMMENT AVEZ-VOUS CONNU LE CABINET ?<\/label><input type=\"text\" id=\"wpforms-933-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><\/div><div id=\"wpforms-933-field_62-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_62\">AUTRES REMARQUES UTILES :<\/label><textarea id=\"wpforms-933-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" ><\/textarea><\/div><div id=\"wpforms-933-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-933-field_63\">DATE <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-933-field_63\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\/99\/9999\" name=\"wpforms[fields][63]\" placeholder=\"JJ\/MM\/AAAA\" required><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6Lcj-wsjAAAAAK7P98gX82HufRuPZR88yuyzI7g-\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"933\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/dentiste-mbemba.be\/index.php\/wp-json\/wp\/v2\/pages\/929\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-933\" class=\"wpforms-submit\" data-alt-text=\"Envoi...\" data-submit-text=\"Envoyer le formulaire\" aria-live=\"assertive\" value=\"wpforms-submit\">Envoyer le formulaire<\/button><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Historique m\u00e9dical &#038; dentaire &#8211; ADULTE<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-929","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.9 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Historique m\u00e9dical et dentaire ADULTE - Cabinet Dentaire Mbemba<\/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:\/\/dentiste-mbemba.be\/index.php\/historique-medical-dentaire-adulte\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Historique m\u00e9dical et dentaire ADULTE - Cabinet Dentaire Mbemba\" \/>\n<meta property=\"og:description\" content=\"Historique 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