Medical Questionnaire
Please tell us your health condition in detail.
Mail Adress *
Today *
MM
/
DD
/
YYYY
Name *
Date of birth
MM
/
DD
/
YYYY
Mobile phone Number *
Home or Office phone number
Address *
Occupation *
How should we contact you? *
How did you find out us? (Multiple answers allowed) *
Required
What are your symptoms?(Multiple answers allowed) *
Required
When did you go to the Dentist last time? *
Do you have any allergy?(Multiple answers allowed) *
Required
What illnesses have you had in the past?(Multiple answers allowed) *
Required
Are you currently taking medication?(Multiple answers allowed) *
Required
Are you currently taking supplement? *
Have you ever been scared or bad feeling during dental treatment? *
What is your preference for treatment?(Multiple answers allowed) *
Required
What kind of treatment do you want ?(Multiple answers allowed) *
Required
What time is better to come?(Multiple answers allowed) *
Required
Treatment Policy(Multiple answers allowed) *
Required
Are you interested in "healthy life program" Dental checkup??(you can know the plan and cost through whole body and mouth checkup)
Clear selection
Have you ever travel abroad in the past 14 days? *
Did you have a chance to see who travel abroad in the past 14 day? *
Is the person living together isolated or having a cold? *
Did you join the Event or meeting over 50 people in the past 1 month? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy