Date

Your Full name (required)

Date of birth

Your Email (required)

Contact telephone number

Country

City/town

Have you used dentist's services previously
NoLess than 1 year agoLess than 5 years ago

The following information is very important for us in order to provide you with dental services in most effective and safe way in accordance with condition of your health. Insufficient and misleading information could do harm to your health. Please, answer all the questions. If you do not understand the question or you are unsure, discuss it with your doctor.

1. Your weight

2. Your height

3. Are you at present under observation of general doctor?
YesNo
If «YES», specify the reason

4. Do you meet all medicines or products?
YesNo
If «NO», please, specify: each medicinal agent or product that caused undesirable reaction, and describe in short the consequences

5. Have you used local anesthesia previously (Novocain, Lidocaine or other), when it was for the last time and how did you meet it? (Did you feel weakness, excessive sweat, shortness of breath, faints or other sense of discomfort?)

6. Do you know the level of your arterial pressure?
YesNo
If you know, specify figures of pressure that is usual for you

7. Have you ever had any excessive bleeding requiring special treatment?
YesNo

8. Are you on a special diet?
YesNo

9. Do you suffer from oncological disease?
YesNo

10. BLOOD GROUP RHESUS

11. Do you take treatment at present or did you take treatment previously from the following diseases?:

a) Heart disease (infarction, stenocardia, cardiac failure, other diseases):
YesNo
If «YES», specify them
Specify what medical products you use for treatment of these diseases and in what doses you take them.

b) Respiratory illnesses (chronic bronchitis, bronchial asthma, tuberculosis or other illnesses):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

c) Digestive tract diseases (gastric ulcer or dodecadactylon or other):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

d) Hepatopathy (jaundice, hepatitis):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

e) Neuropathy (paralyses, convulsive disorder, faints or other):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

f) Haemopathology (haemophilia, hypercoagulability or hematolysis or other):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

g) Endocrinopathy (diabetes, thyrotoxicosis, hypothyroidism, Basedow's disease, myxoedema, Derbyshire neck or other):
YesNo
If «YES», specify: what illnesses and what medical products you use for treatment.

12. How many times per year you have cold-related diseases

When you were ill for the last time

Do you use antibiotics for treatment of these diseases:
YesNo
If «YES», specify what antibiotics and when did you use for the last time

Have you ever used:
Penicillin? YesNoI do not know
Erythromycin? YesNoI do not know
Tetracycline or Doxycycline? YesNoI do not know
Biseptol? YesNoI do not know
If there were undesirable effects, specify their consequences

13. Do you have problems with your health (specify something that is important to your mind)?

SPECIAL DATA (for patient ladies):
• Do you take antifertility agents in pills at present?
YesNo
If «YES», specify the name of the pills

• Are you pregnant at present?
YesNo
If «YES», specify duration of pregnancy , if «NO», specify whether you are going to be pregnant during in the nearest time.

14. Short description of the dental problem:

15. Supposed terms of the treatment:

16. Panoramic X-ray

17. Intraoral camera images

18. Digital camera images