Please, do not hesitate and quite frankly, fill out a questionnaire about your health. Do not leave out any relevant information regarding your teeth issue as well as your general health, because it can be of vital importance.

Rest assured that the information will be kept strictly confidential and available ONLY BUT to the medical personnel of this institution.

    Your Name (*)

    Your Email (*)

    Your Permanent Address (*)

    Your Telephone Contact (*)

    Date

    Time

    WARNING!

    Diagnosis

    01I suffer from Epilepsy

    02I have a high blood pressure

    03I have had

    04 I have implanted

    05 I bleed a long time after skin cuts, tooth extractions or surgery

    06I suffer from :

    07I suffer from excessive blood clotting:

    08 I suffer from Bronchial Asthma

    09 I I have had

    10I suffer from Ulcer

    11I have had Hepatitis:

    12 I suffer from:

    13I suffer from AIDS

    14I have had:

    15I am allergic to:

    16I suffer from the illnesses not stated in the questionnaire

    17Momentarily I am taking the following medicaments:

    18How many cigarettes you smoke per day?

    19 I drink alcohol daily

    20I am taking narcotic drugs