Please enable JavaScript in your browser to complete this form. - Step 1 from 4Patient code (example: K12345) - you have received this from us *.Data protection is very important to us, therefore medical and personal data is only sent in encrypted form. For additional protection, we ask you not to enter any data that can be traced back to you. The patient code allows us to assign the sent data to your file. NextBefore we can discuss your medical wishes in peace, we will need information about you as well as information about your general state of health. This is because general illnesses are related to our therapy. Therefore, we ask you to fill out this questionnaire. It will be attached to your personal documents. All information is, of course, subject to medical confidentiality.InsuranceHow are you insured *statutoryprivateSelf-paySupplementary dental insurance *YesNoEligible *YesNoPrime rate *YesNoWho is your family doctor?Who is your family dentistReminder service - Would you like us to remind you by SMS of your preventive check-up, current treatment appointments or prophylaxis in consultation with you? *YesNoPlease note that your ability to drive on the road after surgical treatment may be impaired for up to may be impaired for up to 24 hours. This can be caused both by the treatment itself and by the influence of injections or other medications. If you wish, we will therefore be happy to call a cab to take you home safely.We are an order practice, which means that we take time for you and reserve appropriate preparation and treatment times for you. reserved for you. Thus, your waiting time can also be reduced to a minimum! If you are prevented from coming, please please cancel your appointment at least 24 hours in advance. This way we still have time to make this blocked appointment available to another available to another patient.When were you last x-rayed in the head/jaw area: *Jaw area X-ray *I do not remember when I was x-rayedDo you have an X-ray passport? *YesNoFor patientsIs there a pregnancy?YesNoIn which week of pregnancy? *General health questionsAre you under constant medical treatment? *YesNoWhy:Do you bruise quickly? *YesNoDo you suffer from poorly healing wounds? *YesNoDo you suffer from prolonged bleeding after injury? *YesNoDo you grind your teeth? *YesNoAre you often tired and sleepless in the morning? *YesNoDo you wear a dental splint? *YesNoCardiovascular diseasesLow blood pressure *YesNoHigh blood pressure *YesNoPacemaker *YesNoEndocarditis *YesNoHeart valve replacement *YesNoAngina pectoris *YesNoStroke *YesNoCoagulation disorder *YesNoDo you have a cardiac passport? *YesNoHeart attack *YesNoWhen: *Heart defects *YesNoWhich: *NextVegetative and chronic diseasesDizziness *YesNoFainting *YesNoAsthma *YesNoDiabetes *YesNoGastrointestinal diseases *YesNoKidney diseases *YesNoRheumatism *YesNoStone formation (e.g. kidney, bile, salivary gland) *YesNoRinging in the ears / tinnitus *YesNoGlaucoma (glaucoma) *YesNoCOPD *YesNoEpilepsy *YesNoMultipleSclerosis (MS) *YesNoDepression *YesNoOsteoporosis *YesNoDo you feel that you are under a lot of physical strain? *YesNoDo you feel a great deal of psychological stress? *YesNoThyroid diseases *YesNoWhat thyroid disease? *HyperfunctionSubfunctionOtherTumor diseaseDo you have a tumor condition? *YesNoWhat ailment? *Has it been operated on? *YesNoChemotherapy *YesNoIrradiation *YesNoInfectious diseasesHIV *YesNoHepatitis (A,B,C) *YesNoTuberculosis *YesNoTake regularlyAnticoagulants (e.g. ASA, Marcumar)Cardiac drugsPainkillerCortisoneAntidepressantsAre you taking any other medications? *YesNoWhich: *Are you receiving or have you ever received bisphosphonate therapy? *YesNoDo you smoke? *YesNoIf yes, how many cigarettes per day? *Do you have an allergy passport? *YesNoAre you allergic to certain medications or substances *NoPainkillerPenicillinIodineLatexLocal anestheticsOther substancesWhich: *Have you ever had any intolerances to injections/medications at the dentist? *YesNoWhich: *How did you hear about our practice?Google searchFacebookPractice signPhone bookNewspaperOther:Other:Have you ever visited one of our dentists in the past in the practice ofYesNoI am not sureQuestions / Notes:NextVorschau aktualisieren...Sign online now *Signatur löschenDSGVO consent *I consent to this website storing my submitted information so that my request can be answered.BackSubmit