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Dental Online Assessment Form
Questioner
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* Указва задължителен въпрос
Names (as they appear in your passport)* *
Вашият отговор
Gender *
Date of Birth* *
ДД
.
ММ
.
ГГГГ
Nationality *
Вашият отговор
Address *
Вашият отговор
Email Address* *
Вашият отговор
Mobile Phone* *
Вашият отговор
Describe the look and the results you expect:* *
Вашият отговор
Have you consulted other specialists for this treatment?
Вашият отговор
Do you have any medical conditions that would prevent treatment? *
Вашият отговор
When was the last time you had a tooth extracted? *
Вашият отговор
Have you had a Periapical (radicular) cysts? *
Do you drink alcohol if so – how often?
Вашият отговор
Do you smoke? *
Do you have heart problems? *
Do you have problems with blood vessels? *
Do you have cerebral problems? *
Do you have diabetes? *
Do you have lung ailments (asthma, respiratory failure)? *
Вашият отговор
When you receive a cut does it heal quickly? *
Are you being treated for any illness right now? If you are please list the medication you are taking. *
Вашият отговор
Do you or have you ever taken narcotics? *
Do you carry any STD and what? *
Вашият отговор
Do you have HIV?
Изчистване на избора
Do you have hepatitis?
Изчистване на избора
Have you ever been hospitalized? *
Do you feel sharp pain in the right arm or chest aria when exercising? *
Do your feet swell up? *
Do you have Thrombophlebitis? *
Do you have normal blood pressure? *
Do you have allergies? What kind of? *
Вашият отговор
Do you get nausea or get sick easily? *
Изпращане
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