Duo Dent Pro - Private dental practice - Questionnaire new patients

1. Blood pressure problems ?

Yes No

If Yes, state your (most common) blood pressure.

2. Heart disease?

Yes No

If so, state which heart disease.

3. Diabetes ?

Yes No

If you are diagnosed with diabetes, state which type and whether it is controlled or not.

4. Hepatitis ?

Yes No

If you have hepatitis, state the type.

7. Have you previously undergone surgery ?

Yes No

If you have, state what kind of surgery and when.

8. Are you currently receiving any medical treatment ?

Yes No

If so, indicate what kind of treatment.

9. Are you pregnant or breastfeeding at the time of completing the questionnaire? (for women)

Yes No

10. Physical disability ?

Yes No

If there is one, list the kind.

11. State the reason why you want to make an appointment.

Routine dental check-up
Pain
Problem with crooked teeth (orthodontic examination)
Bleeding gums or loose teeth
You have lost (extracted) teeth and want a prosthetic examination because of their replacement.
You want to clean and polish your teeth
Aesthetic treatment
You are interested in implant placement
There is another reason why you are making an appointment; state it:

12. Do you have a panoramic X-ray of your teeth ?

Yes No

If so, when was it made ?

Questionnaire for new patients

Telephone number:

Location:

Work hours:

Language:

Questionnaire for new patients!

It would be beneficial to fill in the questionnaire before coming to us in the office, i.e., before making an appointment, to be adequately acquainted with your health and provide you with better and safer dental treatment.
Your data will be for internal use only.

Name*

Surname*

Date of birth*

Adress

Telephone number*

E-mail

1. Blood pressure problems ?

2. Heart disease?

3. Diabetes ?

4. Hepatitis ?

5. AIDS ?

6. Chemotherapy ?

7. Have you previously undergone surgery ?

8. Are you currently receiving any medical treatment ?

9. Are you pregnant or breastfeeding at the time of completing the questionnaire? (for women)

10. Physical disability ?

11. State the reason why you want to make an appointment.

12. Do you have a panoramic X-ray of your teeth ?

Schedule an appointment

Questionnaire for new patients

Telephone number:

Location:

Work hours:

Language:

Questionnaire for new patients!

It would be beneficial to fill in the questionnaire before coming to us in the office, i.e., before making an appointment, to be adequately acquainted with your health and provide you with better and safer dental treatment. Your data will be for internal use only.

Name*

Surname*

Date of birth*

Adress

Telephone number*

E-mail

1. Blood pressure problems ?

2. Heart disease?

3. Diabetes ?

4. Hepatitis ?

5. AIDS ?

6. Chemotherapy ?

7. Have you previously undergone surgery ?

8. Are you currently receiving any medical treatment ?

9. Are you pregnant or breastfeeding at the time of completing the questionnaire? (for women)

10. Physical disability ?

11. State the reason why you want to make an appointment.

12. Do you have a panoramic X-ray of your teeth ?

Schedule an appointment

It would be beneficial to fill in the questionnaire before coming to us in the office, i.e., before making an appointment, to be adequately acquainted with your health and provide you with better and safer dental treatment.
Your data will be for internal use only.