Page 1 of 1

Patient history

Please fill out this questionnaire thoroughly. Your information helps us plan your treatment safely and individually. All submissions are confidential and subject to GDPR.

1. Personal Information

Name:

*

Last name:

*

Sex:

*

Do you have preffered pronouns?

Date of birth:

*

Current address:

*

Phone:

*

Mail:

*

Are you covered by family insurance?

*

Do you have additional private dental insurance?

*

2. General Health

Do you have or had any of the following illnesses?

*

Do you have or had any of the following illnesses?

Heart disease

Heart attack/Bypass/Valve replacement

Cardiac arrhythmias/Pacemaker

Low blood pressure

High blood pressure

Stroke/Circulatory disorder

Asthma/Chronic bronchitis

Diabetes

Hyperthyroidism

Hypothyroidism

Kidney disease/Dialysis

Rheumatism/Rheumatoid arthritis

Epilepsy/Seizures

Glaucoma

Tumor disease/Chemotherapy/Radiation

Blood clotting disorder

none

other disease

3. Medications/Allergies

Do you take medication regularly?

*

Do you have an up-to-date medication plan?

*

Are you taking blood thinners? (Falithrome, Marcumar, ...)

*

Do you have any allergies or intolerances?

*

Do you have an allergy passport?

*

4. Other important information

Do you smoke or vape?

*

Do you consume alcohol or drugs on a regular basis?

*

Have there ever been any side effects after anesthetic injections?

*

Do you suffer from headaches or migranes on a regular basis?

*

Has your weight changed significantly and unintentionally recently?

*

Do you wear contact lenses?

*

5. Service & Consent

Would you like to receive reminders (recall) for appointments and check-ups via SMS?

*

I confirm that the information provided is complete and correct to the best of my knowledge.

*

I confirm that I have read and understood the terms concerning the security of my my data

*

Signature

I confirm that I have read and understood the terms for scheduling appointments

*

Signature

Please sign here:

*

Signature