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FDI health questionnaire

Please fill out the FDI questionnaire on health. The entered data is confidential, the patient's identity will not be available to the public in any form.

Name

Sex

Last name

Telephone number

E-mail

Street

City

State

Occupation (job)

How did you hear about Dentalis Art?

web or social networks

recommendation of our patient

referred by another doctor

Doctor's name

The main reason for coming

Please answer all questions

Do you suffer from any disease?

Do you use any medications constantly or occasionally?

Have you been treated in the last two years?

Have you been in the hospital in the past two years?

Have you personally or a member of your family had a problem with anesthesia?

Are you allergic to any medicine or anything else?

Have you had problems with blood clotting?

Have you been irradiated in the head and neck area?

Do you have any infectious disease?

Are you HIV positive?

Are you addicted to narcotic drugs?

Are you pregnant?

Mark the diseases (conditions) you had or have

High blood pressure

Damage to the heart valves

Artificial heart valve

Congenital heart defects

Endocarditis

Allergies

Epilepsy

Malignant diseases (cancer)

Bronchiectasis

Thyroid diseases

Sugar diseases

Sinus infection

Chronic cough

Tuberculosis (TB)

.

Arthritis

Pacemaker

Psychiatric treatment

Enlarged glands

An ulcer in the digestive system

Anemia

Increased eye pressure

Venereal diseases

Hepatitis

Asthma

Leukemia

Oral candidiasis

Jaundice

Chronic secretion from the lungs

Signature

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