Medical Questionnaire

CONTACT INFORMATION

GENDER(Required)

Woman

Man

FULL NAME(Required)

Firstname Lastname

DATE OF BIRTH(Required)

Day

Month

Year

PHONE NUMBER(Required)

EMAIL(Required)

NAME OF YOUR DENTIST(Required)

ABOUT YOU

Do you smoke?(Required)

yes

Are you pregnant?(Required)

Yes

Specify

how many months...

Do you have allergies?

to iodine ?(Required)

Yes

To latex?(Required)

Yes

To medications?(Required)

Yes

Specify

Other Information

YOUR HEALTH

Are you taking blood thinners or Aspirin?(Required)

Yes

Specify

Do you have osteoporosis?(Required)

Yes

Do you have any current or previous treatment? Which one?

Have you undergone any major surgery?(Required)

Yes

Specify

Do you have a stomach ulcer?(Required)

Yes

DO YOU HAVE ANY HEALTH CONDITIONS?

Heart(Required)

Yes

Specify

Vascular(Required)

Yes

Specify

Glandular(Required)

Yes

Specify

Liver(Required)

Yes

Specify

Diabetes(Required)

Yes

Specify

Blood disorders(Required)

Yes

Specify

HIV(Required)

Yes

Specify if viral load undetectable

YOUR MEDICATIONS

Are you currently taking any medications?(Required)

Yes

Specify which ones and why?

Are you taking bisphosphonates ?(Required)

Yes

Specify the oral or injectable form, the frequency and since when?

is there anything else we should be aware of ?(Required)

Yes

Specify

You may send us an X-ray or written recommendations from your dentist.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, bmp, pdf, Max. file size: 4 MB, Max. files: 2.

I declare that I am aware that(Required)

The Endodontie Louise Pratice does not follow the INAMI agreement and can use INAMI pseudo-codes and that the price of your treatment was communicated to you by telephone or during the pre-operative consultation.

PRIVACY CONSENT(Required)

I consent to the storage of this data in accordance with the privacy policy.

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Phone

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Medical questionnaire

CONTACT INFORMATION

ABOUT YOU

Do you have allergies?

YOUR HEALTH

DO YOU HAVE ANY HEALTH CONDITIONS?

YOUR MEDICATIONS

ENDODONTIE LOUISE

Endodontic Dental Practice in Ixelles

Phone: 02/354.44.69
Email : info@endodontielouise.be

Address:
Avenue Louise, 391 B10
(5th floor)
1050 Ixelles, Brussels.
Public transport:
tram 8 & 93: stop “Abbaye”

Monday to Friday:
09:00 – 18:00
Saturday – Sunday:
closed

Medical Questionnaire

Medical questionnaire

CONTACT INFORMATION

ABOUT YOU

Do you have allergies?

YOUR HEALTH

DO YOU HAVE ANY HEALTH CONDITIONS?

YOUR MEDICATIONS

ENDODONTIE LOUISE

Endodontic Dental Practice in Ixelles Phone: 02/354.44.69Email : info@endodontielouise.beAddress:Avenue Louise, 391 B10(5th floor)1050 Ixelles, Brussels.Public transport:tram 8 & 93: stop “Abbaye” Monday to Friday:09:00 – 18:00Saturday – Sunday:closed

Endodontic Dental Practice in Ixelles

Phone: 02/354.44.69
Email : info@endodontielouise.be

Address:
Avenue Louise, 391 B10
(5th floor)
1050 Ixelles, Brussels.
Public transport:
tram 8 & 93: stop “Abbaye”

Monday to Friday:
09:00 – 18:00
Saturday – Sunday:
closed