Medical questionnarie form




Dear Patient.

Filling out this data sheet is required for a safe and efficient dental treatment. From your answers we learn your health problems from the past, your drug sensitivity and your current health status. This knowledge is the base for starting your treatment. Please read the questions carefully and help our work with your answers. If you need any support please talk to our colleagues. Your data will be handled with maximum discretion aligned with the operative data management laws of Hungary.

How did you first hear about Evergreen Dental?


Personal details

Contact details






Emergency contact

Person to be contacted in case of urgency


Insurance



Mark your answer at the corresponding place. If yes, please write the details next to it.

Health condition

Do you do sports?

Please mark your answer

Do you have anxiety or fear of the dentist?

Did you ever get a local anaesthesia?

Was there any complication during the local anaesthesia?

Allergy (drug, dental-medical materials, food, pollens, other)?

Drug sensitivity?

Metal sensitivity?

Does a pregnancy exist at the moment?

Have you been in a hospital in the past 2 years?

Did you ever have a surgery?

Do you smoke?

Are you taking any medication currently?


Do you have, or did you ever have any of the following illnesses?

Illnesses

Contagious illnesses? ( HIV, AIDS, Hepatitis, Herpes, TBC, other)

Did you have any tumorous illness which was treated with irradiation and/or chemotherapy?

Illnesses in connection with blood (haemophilia, anaemia, thrombosis)?

Circulatory illnesses (heart trouble, high blood pressure)?

Lung disease (asthma, bronchitis, lung inflammation, TBC)?

Diabetes?

Rheumatism, joint discomfort or muscle discomfort?

Illnesses of stomach and/or intestinal (ulcers, malabsorption)?

Kidney disease?

Nephritic illnesses? Illnesses of the nerve system (epilepsy, dizziness, faint, migraine, other)?

Illnesses of the hormone system (sign gland, adrenal gland, other)?

Inherited illnesses (cardiac defect, other)?

Immune illnesses (autoimmune illness, immune insufficiency)?

Nutritional disorders (oral dryness, reflux, anorexia, bulimia)?

Often returning illness (ear, sinus, pharynx inflammation.)?

Other illnesses?


Other information of importance for us?

Other