Health form

Helbredsskema – Engelsk

Address

Contact information

Questions

To ensure we give you the best possible treatment, we kindly ask you to answer the following questions:
Are you currently undergoing treatment at a hospital? *
Have you previously experienced any problems with local anasthesia? *
Have you previously experienced prolonged bleeding after tooth extractions or other surgeries? *
Do you smoke? *

Diseases

Do you suffer from any of the following diseases?
Asthma? *
Diabetes? *
Cardiovascular diseases? *
Hypertension (high blood pressure)? *
Osteoporosis? *
Epilepsy? *
Cancer *
HIV/AIDS *
MRSA? (methicillin resistant staphyloccoci)? *
Hepatitis? *
Immunodeficiency disorders? *
Other severe diseases? *
May we request a copy of your dental and medical records as well as x-ray from your dentist or medical doctor/physician? *
May we use your data for teaching and research in anonymized form? *
Are you pregnant or breastfeeding? *
Have you ever recieved radiotherapy in the head/neck area? *
Are you allergic to any types of medication? *
Do you tolerate penicillin? *
Do you tolerate NSAID (ibuprofen)? *
Have you previously undergone surgery in jaws or sinuses of the head? *
If so, which surgery? *
Do you take any medication (prescription or other)? *

Medication

Medical doctor/physician

Own dentist