Anamnesis Form Smile To Win

Dear patient! (optional)

Please fill out this form carefully, it serves our preparation for your treatment. Unless marked as optional, all fields must be completed. Of course, the information provided is subject to medical confidentiality. If individual questions or information do not apply to you, please note this briefly (e.g. with not applicable).

1. Personal Data

Are you the patient or the caregiver?

I am the patient

I am the caregiver

Do you receive social support?

Yes

A. Patient data

First name(s)

Family name(s)

Birthday

Street and house number

Zip code

City

Canton/Province

Country

Phone (mobile and/or landline)

Occupation (optional)

B. Caregiver data / invoice recipient

These fields under B are to be filled in only if the data differ from section A.

First name(s) of caregiver (optional)

Family name(s) of caregiver (optional)

Street and house number (optional)

Zip code (optional)

City (optional)

Canton/Province (optional)

Country (optional)

Phone (mobile and/or land line) (optional)

Email (optional)

Occupation (optional)

2. Health condition

Diseases and medications of all kinds can have an impact on dental treatment. Therefore, we ask you to carefully complete the following questions. Your medical history will be attached to your personal records and is, of course, subject to medical confidentiality.

Drug allergy (e.g. penicillin)

Yes

If yes, which one(s)? (optional)

Other allergies

Yes

If yes, which one(s)? (optional)

Blood pressure

low

normal

high

If known, please provide your blood pressure values (optional)

Glaucoma

Yes

Blood clotting disorder / bleeding tendency

Yes

Heart disease / cardiac arrhythmias

Yes

Cardiovascular disease

Yes

Do you have an artificial heart valve?

Yes

Do you have a pacemaker?

Yes

Are you taking blood thinners (e.g., Marcumar, Aspirin)?

Yes

Diabetes

Yes

Infectious diseases (Hepatitis A B C,TBC,HIV)

Yes

Liver disease (jaundice, hepatitis)

Yes

Asthma or lung disease

Yes

Kidney disease

Yes

Thyroid disease

Yes

Rheumatism

Yes

Gastrointestinal disease

Yes

Epilepsy

Yes

Do you have an artificial hip/knee joint?

Yes

Other diseases

Yes

If yes, which one(s)? (optional)

Are you currently taking medication on a regular basis?

Yes

If yes, which one(s)? (optional)

Do you smoke?

Yes

If yes, how many cigarettes per day? (optional)

Are you pregnant?

Yes

Not sure

If yes, which month? (optional)

For the protection of mother and child, we ask for immediate notification if pregnancy occurs during the treatment period!

If you know the contact details of your family doctor, please fill in below:

Family doctor's name (optional)

Family doctor's address (optional)

Family doctor's phone (optional)

Please let us know if your health condition has changed.

3. Teeth and mouth condition

Do you have bleeding gums?

Yes

Do you suffer from bad breath?

Yes

Do you suffer from receding gums?

Yes

Do you suffer from noises in the temporomandibular joint (e.g. when chewing)?

Yes

Do you have any head and/or neck pain?

Yes

Are you satisfied with the position/color/shape of your teeth, in short: with your "smile"?

Yes

Specify the number of months from your last dental x-ray (optional)

4. Do you have any special requests for your individual treatment planning?

What is the reason for your visit to the dentist? (optional)

Would you like specific advice? If yes, about what. (optional)

What particular concern brings you to our practice? (optional)

How did you hear about us?

Family*

Friends*

Internet

Facebook

Phone book

Emergency service

Medical referral*

Other*

*please specify - referral by whom, what other channel or to whom may we thank you for visiting our practice? (optional)

5. Important notes on the treatment in our practice

Please note that for the sake of your health, we do not use the controversial amalgam. Among other things, we use biologically compatible cement fillings or all-ceramic inlays, so no metal.

Should you ever have pain or problems outside of your appointment, we offer special times for this. In this case we kindly ask you to make an appointment by phone in advance.

If you are unable to keep the appointment, please cancel by phone or in writing at least 24 hours before the agreed appointment (exception: sudden illness), otherwise the reserved time will have to be charged. We kindly ask for your understanding in this regard, as otherwise we cannot give important treatment time to other patients who may urgently need an appointment.

Please keep in mind that medication and anesthetic injections can impair your ability to react in traffic.

Please notify us immediately of any changes in your medical condition.

We hope you feel comfortable in our office and are happy to answer any questions you may have.

6. Declaration of consent for invoicing

I agree to dental fees - also for future treatments - being collected if the amount has not been paid within the agreed payment period despite several requests.

For this purpose, the dentist may pass on the data required in each case (in particular names, date of birth, address, date of treatment, service items, amounts, findings) to the debt collection agency and, if necessary, also to lawyers and courts for further processing.

This declaration is valid until I revoke it in writing.

I hereby confirm that I have understood and answered the above questions to the best of my knowledge and that all information I have provided about myself is correct.

Yes

You can find our privacy policy under this link.

Thank you for your cooperation. We look forward to welcoming you to our practice soon!

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