Dr. Jerecinski - Medical history sheet

Personal information


Date of Birth

Contact information


General Medical History Questions and Answers

Blood Thinner (ASS, Markumar, Heparin, Equilis)

Bisphosphonates (Zometa®, Fosamax®)

Cardiovascular Disorders (Pacemaker, Heart Attack, Blood Pressure)

Stroke (Apoplex)

Allergies and Sensitivities

Lunge Disorders (Asthma, COPD, Chronic Bronchitis)

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

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


Pregnant / Breast Feeding

Blood Disorders (Hemophilic, Anemic)

Infectious Diseases (Hepatitis, TBC, HIV, AIDS)

Chemotherapy, Radiotherapy

Mental Health (Depression, Bulimia, etc.)

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

Dental History Questions and Answers

Orthodontic Therapy

Gum Disease (Bleeding Gums, Gingivitis, Periodontitis)

Jaw joint complaints (pressing, crunching, muscle tension)



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.