Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.HEALTH QUESTIONNAIRE – PERIODICDear patients! We kindly ask you to fill out the questionnaire, which will provide us with a better insight into your overall health condition and thus enable us to adjust dental care accordingly. All fields marked with * are mandatory.Name and Surname *Gender *MaleFemaleDate of Birth *Please update your information if there have been any changes.AddressPostal CodeCityCountryEmail Phone Number Occupation / Education The data is confidential and serves DMC PRAPROTNIK d.o.o. only for medical purposes. 1. Have you been hospitalized or seriously ill in the past two years? *YesNo2. Have you taken any medications in the last year? *YesNoa.) If so, which ones? 3. Are you allergic to any medications or materials? *YesNoa) What are you allergic to?AspirinPenicillinLatexDental materialsLocal anestheticNalgesinNaklofenBrufenDiverinKetonalNaprosynOther:b.) To which other medication are you allergic?4. Do you have any other allergies? *YesNoa.) Which allergy do you have? 5. Have you ever experienced blood clotting disorders? *YesNo6. Have you received radiation therapy to the head or neck? *YesNo7. Do you have any autoimmune diseases? *YesNoa.)Which autoimmune disease do you have?8. Do you use tobacco and related products (cigarettes, snus, electronic cigarettes, vapes, etc.)? *YesNoa.) Which tobacco and related products do you use?b.) How many per day?c.) How many years?9. Have you stopped using tobacco and related products? *YesNoa.) When did you stop?10. Have you ever been treated with bisphosphonates for osteoporosis? *YesNo11. Do you have any electronic devices implanted (e.g., pacemaker)? *YesNoa.) Which electronic device do you have?12. Mark the diseases and conditions you have or have had in the past.Heart valve defectsArrhythmiaArtificial heart valveInfective EndocarditisCongenital heart defectsHigh blood pressureStrokeHeart attackRheumatoid arthritisAnemiaOsteoporosisLeukemiaEnlarged lymph nodesAsthmaChronic coughRespiratory diseasesTuberculosisDiabetesSinusitisSexually transmitted diseasesMalignomaGlaucomaOral mucosal fungal infectionsJaundiceThyroid diseasesHepatitisEpilepsy (seizures)Psychiatric treatmentPsychiatric treatmentOther:a.) What other disease do you have?13. Do you have any contagious diseases (e.g., herpes, hepatitis, AIDS)? *YesNoWhat infectious disease do you have?14. Do you have any other diseases or conditions not mentioned in the questionnaire? *YesNoa.) What disease do you have?15. Are you pregnant? *YesNoa.) When is the expected due date?Patient's or guardian's Signature: * Clear Signature COMPLETED BY THERAPIST: Questionnaire reviewed by responsible therapistYESNOPošlji
