Full Name

Birth place

Date of birth

Job

Address

Town

E-mail

Phone

Policy Nr

Your Physician's name

Are you currently on medication? Are you currently on medication?YesNo

List medications you are taking

Any hospitalization in the last years? Any hospitalization in the last years?YesNo

Are you using psychotrope drugs? Are you using psychotrope drugs?YesNo

Do you suffer from heart deseases? Do you suffer from heart deseases?YesNo

Have you high blood pressure? Have you high blood pressure?YesNo

Any relative suffering from diabetes? Any relative suffering from diabetes?YesNo

Have you got any problems with ears? Have you got any problems with ears?YesNo

Do you suffer from rheumatic disease? Do you suffer from rheumatic disease?YesNo

Do you suffer from osteoporosis? Do you suffer from osteoporosis?YesNo

Which medication are you on for osteoporosis?

Have you ever suffered from gastric or duodenal ulcer? Have you ever suffered from gastric or duodenal ulcer?YesNo

Have you ever suffered from respiratory problems? Have you ever suffered from respiratory problems?YesNo

Have you ever suffered from eye ailments? Have you ever suffered from eye ailments?YesNo

Have you ever had thyroid deseases? Have you ever had thyroid deseases?YesNo

Do you suffer from coeliac deseases? Do you suffer from coeliac deseases?YesNo

You had suffered from gastrointestinal deseases? You had suffered from gastrointestinal deseases?YesNo

Any asthma or allergy? Any asthma or allergy?YesNo

What are you allergic to?

Any blood deseases? Any blood deseases?YesNo

Have you ever had a bad reaction to local anaesthetics, Antibiotics or any other drugs? Have you ever had a bad reaction to local anaesthetics, Antibiotics or any other drugs?YesNo

List drugs/medecine allergies

When was your last visit to a dentist?

Enter any other information