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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