F12 ENG- Health Questionnaire - CeraRoot CLINIC
FORM F12 - VER.14/05/2021
Email *
Personal Data
History nº (if known)
Name *
Last Name *
DNI - Passport *
Date of birth: *
MM
/
DD
/
YYYY
Reason of the appointment *
Required
Did you have... / Do you have ... ?
Any heart condition or injury? *
(If yes, please mark "other" and describe.)
Hypertension? *
Diabetes? *
Cholesterol? *
Hyperglycemia? *
Uric Acid? *
Virus AIDS O VIH? *
Any other infectious/transmisible disease? *
(If yes, please mark "other" and describe.)
Have you ever been surgically intervented? *
(If yes, please mark "other" and describe.)
Have you ever received a blood transfusion? *
(If yes, please mark "other" and describe.)
Have you visited a doctor in the last 6 months? *
(If yes, please mark "other" and describe.)
Are you taking any medication in present? *
(If yes, please mark "other" and describe.)
Are you pregnant? *
Do you smoke? *
(If yes, please mark "other" and describe the quantity.)
Do you drink alcohol regularly? *
Do you consume any marihuana, cocaine or other drug? *
(If yes, please mark "other" and describe.)
Do you have any allergy to any object or food? *
(If yes, please mark "other" and describe.)
Are you allergic to any medicine? *
(If yes, please mark "other" and describe.)
Have you had any tooth extracted? *
Have you had continuous bleeding after a tooth extraction? *
Do your gums bleed when you brush your teeth? *
Have you observed mobility on any tooth? *
Is something not feeling well in your mouth? *
(If yes, please mark "other" and describe.)
have you had any accident that might affect your mouth or teeth? *
Do you have any digestive problem? *
(If yes, please mark "other" and describe.)
Do you swallow your the food without having chewed it enough? *
Do you clench your teeth (bruxism) ? *
Have you noticed if your teeth look shorter? *
Have you been diagnosed with gingivitis or periodontal disease (pyorrea)? *
Do you wear any fixed prosthesis? *
Do you wear any removible prothesis? *
How many times a day do you brush your teeth? *
When was your last visit to the dentist? *
Date of last professional hygiene
Date of last blood analysis
Other comments:
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Legal Notice *
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