QUESTIONNAIRE I. PERSONAL DATAAgeSexFMDate of birthIdentification No.PhoneE-mailAddressOcupaciónII. GENERAL MEDICAL HISTORY1. Are you currently under medical treatment?YesNoWhich one?2. Do you take medication regularly?YesNoWhich ones and why?3. Are you allergic to any medication, food or substance?YesNoWhich one(s)?4. Have you been hospitalized or undergone surgery?YesNoWhy?5. Do you have or have you had any of the following diseases?YesNoSeleccionarDiabetes6. Are you pregnant or breastfeeding?YesNoNone of the above7. Do you smoke?YesNoHow many cigarettes a day?8. Do you consume alcoholic beverages?YesNoHow oen?9. ¿Consume alguna droga o sustancia no prescrita?YesNoWhich one?III. DENTAL HISTORY1. How oen do you go to the dentist?SíNoSeleccionarOnly when discomfort is present2. Have you had previous treatments of:OrthodonticsYesNoDental surgeryYesNoImplantsSíNoEndodonticsYesNoPeriodontal treatmentsYesNo3. Do you suffer or have you suffered from:SíNoBleeding gumsYesNoDental sensitivityYesNoLoose teethYesNoPersistent bad breathYesNoBruxism (teeth grinding)YesNoChewing painYesNo4. Do you have any dental prosthesis (fixed or removable)?SíNo5. Are you satisfied with your current oral health?SíNoWhy?6. Do you have any goals or expectations with your treatment?SíNoIV. DECLARATION AND CONSENTI declare that the information provided is true and complete. I agree to inform the dental health professional of any changes in my health status or medical treatments.Patient's signature:Date:EnviarPlease do not fill in this field.
