Dr. Jerecinski - Medical history sheet

Personal information

Salutation

First name

Last name

Date of Birth

Post Code

City

Street

Contact information

Mobile

Telephone

E-mail

Gender

Insurance

Additional insurance

General Medical History Questions and Answers

Blood Thinner (ASS, Markumar, Heparin, Equilis)

Yes

Bisphosphonates (Zometa®, Fosamax®)

Yes

Cardiovascular Disorders (Pacemaker, Heart Attack, Blood Pressure)

Yes

Stroke (Apoplex)

Yes

Allergies and Sensitivities

Yes

Lunge Disorders (Asthma, COPD, Chronic Bronchitis)

Yes

Metabolic Disorders (Diabetes, Kidneys, Liver, Gastrointnstinal, Thyroid)

Yes

Nerve Disorders (Epilepsy, Multiple Sclerosis, Parkinson’s)

Yes

Smoking

Yes

Pregnant / Breast Feeding

Yes

Blood Disorders (Hemophilic, Anemic)

Yes

Infectious Diseases (Hepatitis, TBC, HIV, AIDS)

Yes

Chemotherapy, Radiotherapy

Yes

Mental Health (Depression, Bulimia, etc.)

Yes

Recall / Would you like an appointment reminder by post or e-mail?

Yes

Dental History Questions and Answers

Orthodontic Therapy

Yes

Gum Disease (Bleeding Gums, Gingivitis, Periodontitis)

Yes

Jaw joint complaints (pressing, crunching, muscle tension)

Yes

Signature

Clear

I accept the following privacy policy

I agree that my data will be sent encrypted to the above mentioned dental practice

I am aware that if I forget my insurance card, it must be submitted within 10 days.

I understand that the appointment time is reserved for me, if I cannot come to my appointment it must be canceled at least 24 hours prior to the appointment. This can be done by phone or email.
If I do not cancel on time, I am aware that I can be billed for the costs of the treatment agreed in the appointment (§615 BGB remuneration in the event of delayed acceptance or operational risk).

Data protection is very important to us! You can view our data protection declaration at any time at www.jerecinski.de.