Dental - Patient History

If you wish to visit us, please fill out the following patient history form.

For any information you need, you can contact us with the following information:

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Address
3 Analipseos St. , 552 36 Panorama

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Phone – Fax
2310 344.968

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Email
info@odontiatriko-kentro.gr

For postoperative Instructions, you can click here

Dental - Medical History Form

By filling out the history form, you protect firstly yourself as well as the members of our clinic.

Patient's Fullname *

Father's name

Mother’s name

Date of birth *

Patien's weight *

Home telephone number*

Cellphone number *

Workplace phone number

Email *

Home address *

City *

Postal code *

Recommendator (website, internet)

Custodian

Custodian’s telephone number

Please read carefully the following questions and answer choosing “yes” in every positive response. Please describe further your possible answers in the blank spaces.

Are you a smoker? Do you use electronic cigarette?
YESNO

Do you suffer from asthma?
YESNO

Do you suffer from heart insufficiency or was found liquid in the lungs?
YESNO

Do you have any heart heart problems or complaints regarding its valves?
YESNO

Do you have high blood pressure?
YESNO

Have you ever experienced a stroke?
YESNO

Do you cough often? Do you have bronchitis or emphysema?
YESNO

Do you have apnea during sleep? (interruption of breathing during sleep)
YESNO

Do you suffer from any liver disease, hepatitis or AIDS?
YESNO

Do you have problems with your thyroid glands?
YESNO

Did you have thrombi problems? Do you have excessive bleeding after trauma and difficulty to stop it?
YESNO

Have you ever experienced heart attack? do you suffer from angina pectoris? have you noticed chest pain and tightening?
YESNO

Did you ever had an incidence of epilepsy?
YESNO

Have you or a family member ever experienced a negative reaction after a dental anaesthesia?
YESNO

Do you have pain in the neck or the jaw? Do you suffer from arthritis?
ΝΑΙNO

Is there any possibility for pregnancy?
YESNO

Have you ever taken corticosteroid drugs (cortisone) or drugs that resemble cortisone in the past year?
YESNO

Do you consume alcohol on a daily basis?
YESNO

Do you have diabetes? If yes, then how do you manage it?

Do you suffer from kidney problems? If yes, then how do you manage it?

Do you have any pharmaceutical allergy? If yes, please mention the medications that cause the allergy:

Do you suffer from other medical problems?

Do you follow on daily basis a pharmaceutical or parapharmaceutical treatment? if yes, then which one?