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Patient form
arniadmin
2023-04-07T13:12:16+02:00
Patient
Form
Please, fill in the form below.
Étape
1
sur
4
25%
About you:
Title:
*
Mrs
Miss
Mr
First/Last Name:
*
FirstName
LastName
Date of birth:
*
Day
Month
Year
You e-mail adress:
*
Your phone/mobile number:
*
1) Medical History
Name of your doctor:
*
When was your last medical examination:
*
Day
Month
Year
Have you seen any changes to your health since the last year?
*
Yes
No
Please tick each of the following diseases or problems that you may have had in the past or that you currently have: (Answers will be completed during the interview with the Dentist)
Antidepressants
Asthma
Hormonal Disorders
Diabetes
Glaucoma
Hepatitis A, B or C
Congenital heart lesions
Stomach ulcers
Heart disease
Blood disease
Venereal disease
Pacemaker
Nervous system problems
Prostheses (other than dental)
Acute Articular Rheumatism
Memory loss
Others
Others. Please specify
*
Have you ever had abnormal bleeding during an operation or accident?
*
Yes
No
Have you ever been treated with radiation?
*
Yes
No
Do you currently take any medications?
*
Yes
No
If yes, wich ones:
Antibiotics
Asprin
Insulin
Antihistamine
Tranquilizer
Treatment for blood pressure
Cortisone
isphosphonates (Prevention and bone resorption ...)
Others
Others: please specify:
*
Are you allergic to certain products or medication?
*
Yes
No
If yes, which ones:
Local anesthetic at the Dentist
Antibiotics
Anti-inflammatory or asprin
Iodine and derived products
Latex
Neuroleptic or sleep aid
Metal
Barbiturates
Codeine
Others
Others: please specify :
*
Are you a smoker?
*
Yes
No
If yes, number of cigarettes/day :
*
Veuillez saisir un nombre entre
1
et
100
.
a number between 1 and 100
Madam, Miss, are you pregnant?
*
Yes
No
If yes, how many months?
*
Veuillez saisir un nombre entre
1
et
9
.
Do you think you have any other illness or problem listed in the list above that could help us treat you in the best conditions?
*
Yes
No
If yes, please specify:
*
2) Dental Follow up:
During your previous visits to the dentist, have you encountered particular difficulties?
Gums
Do your gums bleed after brushing, or even spontaneously?
*
Yes
No
Have you ever been treated for your gums?
*
Yes
No
Theeth
Do you have sensitive teeth to :
warm temperature
cold temperature
sugars
acids
chewing
Jaws:
Do you squeeze or grind your teeth?
*
Yes
No
Do you notice cracks or have any pain when you open your jaw ?
*
Yes
No
Do you have difficulty chewing?
*
Yes
No
Habits:
Have you had in the past or do you now have any of the following habits ?
Thumb sucking
Biting of tongue, lip, or cheek
Playing a musical wind instrument
Aesthetic Dentistry:
If you had the opportunity to change your smile, what would you like to change?
Are you satisfied with the appearance of your teeth and gums ?
Yes
No
Various:
Did you wear a device or rings to straighten your teeth? Ideally, what would you like to change in your mouth?
Are you anxious about the idea of dental work?
*
Not at all
A little bit
Moderately
Very
Confirmation:
*
I certify the accuracy of this document and have not omitted anything. I will immediately report any changes in my state of health and medical prescriptions.
Consent:
*
I consent to the storage of my data in accordance with the privacy policy.
Phone
Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.
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