MEDICAL QUESTIONNAIRE


This form is designed for those patients who want to have the most exact information previous to an appointment. This will make your treatment easier and as short as possible.
 
Section a: The mandatory fields are marked by (*)
Full name *:
Address *:
Zip code *:
City *:
State/country *:
Phone *:
Cell phone *:
Email *:
Birthday :  Years
Pattern: 02/02/2006
Gender:
Old patient from our center? Yes: No:
Occupation:
Weight: Kgs.   Lbs
Height: Cm   Pulgada   Pie
What do you prefer for your treatment?:
You knew about IMOI in?:
 
Section b:


GRAPHIC 1: ONLY IN CASE OF EDENTULISM (PARTIAL OR TOTAL)

In the following pictures you can see a full upper and lower denture. Please mark the absent teeth or the places where you are interested to put implants.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

 

GRAPHIC 2: ONLY IF YOU NEED EXTRACTIONS

In the following pictures you can see a full upper and lower denture. Please mark the teeth or roots to be extracted. and replace with implants.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

In case of patients with complete or partial removal prosthesis, if you want inmediate implants mark with an X:

  UPPER MAXILLA LOWER MAXILLA
 

If you need dental aesthetics, how important is for you?:

  IMPORTANT VERY IMPORTANT
 
Section c:

Make a list (with capital letters) with all the active medical therapies from last 6 months
Specially write a list with drugs that affect coagulation, sleep or nerves
 
Section d:

Did you ever?
1.- Abnormal reaction with local anaesthesia.
2.- Heart attack, or heart problems.
3.- Hypertension
4.- Hepatitis
5.- A.I.D.S.
6.- Respiratory problems
7.- Are you allergic to any medicine or else? Say what
8.- Are you allergic to any food or else? Say what
9.- Treated with corticoesteroias
10.- Are you Diabetic?:
11.- Nausea or vomiting during dental treatment?
12.- Venereal diseases?
13.- Psychiatric treatment?
14.- Bleeding after oral surgery or any surgery procedure
15.- Do you smoke?: How much?
16.- How many alcoholic drinks every week?:
17.- Any surgical treatment?:
18.- Any important disease?:
19.- What other illnesses have you now:
20.- Are you receiving immunosupressor therapy?:
21.- Is your state of health adequate: Good Regular Bad:
22.- Did you have difficult extractions?:
23.- Bleeding after dental treatment?:
24.- Did you have periodontal disease?:
25.- Grind or clench your teeth:
26.- Did you have been treated with splints for bruxism? :
Upload your X-Ray:
To introduce your panoramic X-Ray see options:
- Take a picture of your panoramic X-Ray, introduce it into the PC and tighten the browse button
- CD. Introdúzcalo y a continuación presione el botón examinar, le aparecerá una ventana desde la cual Ud. podrá acceder al CD. Ask your doctor about your digital panoramic X-Ray, which will give you in a CD format. Insert the CD and the press the browse button, a new window will open and you can access to your CD
 
27.- Wish to receive any diagnosis an approximate budget?
 
You should know that only after a medical and dental survey in our clinic, your will have a final diagnosis and budget. Our diagnosis and budgets without personal contact are just and indication ( with the possibility of being totally wrong) of what could be. Generally helps patients to make decision first
 
Section e:


Make notice whatever kind of information that you think ís important to know.
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