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WELCOME TO OUR DENTAL PRACTICE Last name ________________________________________________ First name _________________________________________________ Date of birth ______________________________________________ Profession _________________________________________________ Street, number ____________________________________________ City, zip code _______________________________________________ Phone at home ___________________________________________ Phone at work _____________________________________________ Mobile phone ____________________________________________ E-mail _____________________________________________________ For children: mother’s name / father’s name _________________________________________________________________________________ How did you hear about our dental practice? ________________________________________________________________________________ General medical history Certain diseases require preventive measures in case of dental treatment. We therefore ask you to answer the following questions completely and correctly. All informations are subject to medical confidentiality. Are you or were you being treated for: Heart disease/Circulatory problems Heart attack? If so when? Pacemaker Yes No □ □ □ □ □ □ Do you have an allergy pass? □ □ □ □ □ □ □ □ □ □ □ □ □ □ Tuberculosis □ □ □ □ □ □ □ □ □ □ □ □ □ □ Hypersensitivity to latex, metals etc. Hepatitis High blood pressure Low blood pressure Blood disease Clotting Anemia Anticoagulant medications Fainting Chronic respiratory diseases AIDS, HIV Yes No □ □ □ □ □ □ □ □ □ □ □ □ Are you suffering from diseases of the immune system? If so which? ________________________________________________ Other diseases:_____________________________________________ Diabetes Gastro intestinal disease (ulcus) Thyroid disease Rheumatism Epilepsy /Cramps Are you currently taking medicaments? _______________________ ___________________________________________________________ Do you smoke? If so how much? Asthma/Hay fever Incompatibility of medications Are you or were you addicted to drugs? Are you pregnant? (which month_____) □ □ □ □ □ □ Family doctor: ____________________________________________________________________________________________________________ We thank you for your disclosures. With my signature I agree that the conditions necessary for the billing, collection and accounting data to the persons and institutions responsible for this will be forwarded. Date__________________________________________________ Signature____________________________________________________