Zahnarztpraxis am Borgweg fileO Stroke O Vascular disorders O Thrombosis Nerves O Seizures/ epilepsy...

Welcome to our surgery!

Prior to your treatment we need some information about your general health in addition to your personal details. We ask you to read and answer the following questions carefully.

All information are subject to medical confidentiality and are treated with absolute discretion.

In our surgery appointments are handled with an electronic ordering system, which allows a short wait. Due to unexpected treatments measures, the schedule could be affected. Therefore, we hope for your understanding and patience in the case of delay.

Please inform us at an early stage, latest 24 h prior to the appointment, if you cannot keep it. Otherwise we might charge you for this circumstance, since we get arising costs of waiting and idle times (§ 304, 611, 615 BGB).

Patient ________________________________________________________________Mr./ Ms./ Child Last name First name Date of birth

Address ________________________________________________________________ Street/Nr. Postal code City

________________________________________________________________

Phone number EmailHealth insurancemember ________________________________________________________________

Last name First name Date of birth Address _______________________________________________________________

Street/Nr. Postal code City

________________________________________________________________Phone number

How did you find us?

______________________________________ _____________ ________________________ Recommendation of Internet else

Health Insurance Company or private insurance: _______________________________________________

☐ I am compulsorily insured ☐ I am insured privately ☐ I wish to submit the invoice for reimbursement (§13 Abs.2 SGB V)

Members profession _______________________________________________________________

Hamburg, _______________________________________________________________

Patients or parents signature

Zahnarztpraxis am Borgweg

Medical history

Do you have afflictions in one of the following areas?

ⵔ single toothⵔ the right sideⵔ the left sideⵔ the upper jawⵔ the lower jawⵔ the maxillary sinusⵔ the gum (gingiva)ⵔ the tongueⵔ the mouth or throatⵔ the jaw jointsⵔ the chewing musclesⵔ the headⵔ new prosthesesⵔ old prostheses

Have you ever had the following:

ⵔ periodontosis treatment?ⵔ orthodontic treatment (e.g. braces)?ⵔ germ identification?ⵔ functional therapeutic treatment?ⵔ a bite tray?ⵔ dental or oral surgical treatment?ⵔ amalgam fillings replaced with another filling?ⵔ heavy metal detoxification? When? How?

What is your sleeping position?

ⵔ supine positionⵔ prone positionⵔ lateral position

Do you grind or press your teeth together?

ⵔ grinding ⵔ pressing

Are you afraid of dental treatments?Especially:

ⵔ injections ⵔ drilling noises ⵔ gag reflex

Do you prefer your treatment with local anesthesia?

ⵔ yes ⵔ no

Your previous dentist, what did you like and what should be improved?

_____________________________________________________________________________________________

In which topics of modern dentistry are you interested in?

ⵔ professional tooth cleaning ⵔ aesthetic dentistryⵔ bleaching ⵔ amalgam removal / restorationⵔ orthodontic surgery ⵔ implantsⵔ general dentistry ⵔ snoring therapy

Stand: 12.07.2016

Please tick as appropriate:

Cardiovascular

O Angina pectorisO Heart attackO Myocardial inflammationO Heart valve inflammationO Artificial heart valveO Cardiac pacemakerO High blood pressureO Low blood pressureO Rhythm disturbances

Skeletal system

O Degenerative joint diseasesO Back complaintsO intervertebral complaintsO Muscular diseasesO Fibromyalgia

Chance of pregnancy?

O YesO No

If yes, which week/month of pregnancy?

Vessels

O StrokeO Vascular disordersO Thrombosis

Nerves

O Seizures/ epilepsyO ParalysesO DepressionsO anxiety

Do you smoke?

O YesO No

How many cigarettes in average?

Lung / Airways

O AsthmaO PneumoniaO TuberculosisO Chronic bronchitisO Sleep apnoea syndromeO Snoring

Eyes

O GlaucomaO CataractO Angle closure glaucoma

Do you drink alcohol sometimes?

O YesO No

Regularly?

Liver

O HepatitisO AO BO CO Other

Blood

O Coagulation disorderO Frequent nose bleedingO Cont. bleeding after surgery

Anticoagulant medicaments

O AspirinO ASSO MarcumarO TiclopidinO ClopidogrelO Plavix

Kidneys

O DialysisO Kidney inflammationO Kidney stones

Allergy

O Hay feverO FoodO MedicamentsO PlastersO Latex

Regular medicaments

O Blood pressureO Novel drugsO PainkillerO The pillO Psychotropic drugsO AntidiabeticsO L-ThyroxinO Other?

Stomach / intestines

O Digestive problemsO HeartburnO Reflux disease

Immunodeficiency

O Taking cortisoneO HIVO Transplantation

Any other diseases or disabilities?

Metabolism

O DiabetesO HypothyroidismO Hyperthyroidism

Bones

O OsteoporosisO Treatment with bisphosphonates?

Stand: 12.07.2016