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Medical questionnaire

Please, fill out this medical questionnare
It is very important to our dentists so they can prepare everything for your first visit, and also estimate the costs of the treatment you are planning.

Health History Questionnaire

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

E-mail Address*
E-mail Address*

Country*
Country*

Home Phone*
Home Phone*

Year of Birth:*
Year of Birth:*

Specific Treatment you need:

Any heart disease:*
Any heart disease:*

	A yes
	B no

Hipertension max.:

Hipertension min.:

Diabetes:*
Diabetes:*

	A yes
	B no

Colesterol:*
Colesterol:*

	A yes
	B no

Hyperglucemia:*
Hyperglucemia:*

	A yes
	B no

Uric acid:*
Uric acid:*

	A yes
	B no

Hepatitis A, B, C:*
Hepatitis A, B, C:*

	A yes
	B no

HIV Virus or AIDS: *
HIV Virus or AIDS: *

	A yes
	B no

Any other transmisible disease:*
Any other transmisible disease:*

	A yes
	B no

If yes, please give details:

Have you ever been surgically intervented?:*
Have you ever been surgically intervented?:*

	A yes
	B no

If yes, please give details:

Have you ever received a blood transfusion?: *
Have you ever received a blood transfusion?: *

	A yes
	B no

If yes, please give details:

Have you visited a doctor the last 6 months?:*
Have you visited a doctor the last 6 months?:*

	A yes
	B no

If yes, please give details:

Are you pregnant?:*
Are you pregnant?:*

	A yes
	B no

Are you allergic to any medicine?:*
Are you allergic to any medicine?:*

	A yes
	B no

Other comments:

Please enter the word that you see below.

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