Patient Form

Medical History / Anamnesis

Please complete the form below, sign it digitally, and either download a copy or send it directly to us before your appointment.

Personal Data

Full Name *

Email *

Phone

Date of Birth

Street / No.

City / Postal Code

Profession

Family Doctor

Previous Dentist

Reason for Visit

Reason / Concerns

Special Request

Patient Questionnaire

Were you hospitalized or under medical treatment during the last years?

Did you take any medications regularly in the last weeks?

Do you take medication for blood thinning?

Have you ever had unusual reactions to injections, foods, or medications?

Have / Had You:

Difficulties with prolonged bleeding?

Heart or circulatory disorders?

Too high or too low blood pressure?

Blood disorders?

Asthma, hay fever, or other allergies?

Stomach or intestinal disorders?

Diabetes?

Severe rheumatism?

Jaundice (Hepatitis A / B / C)?

Frequent ear or headaches?

Do you have an artificial joint replacement or metal objects (piercing, screws, etc.)?

Jaw joint noises, clicking, or pain?

Accidents involving your teeth / head?

Inflammation of the jaw and/or sinuses?

Inflammation of the oral mucosa?

Do you / have you had the feeling of having bad breath?

Do you have osteoporosis?

Any other serious illness?

Dental corrections as a child (orthodontics)?

Are you a smoker?

Have you been regularly seen by a dental hygienist?

Are you HIV-positive (AIDS)?

Is there currently a pregnancy?

Have you been vaccinated against COVID-19?

I give my consent that the necessary billing data may be passed to the persons/institutions commissioned for invoicing.

I give my consent for information to be obtained from my treating physician, if my state of health could affect the dental treatment.

Do you wear a pacemaker or other active implants (insulin pump, hearing aid)?

Do you suffer from a malignant tumor (cancer)?

Do you suffer from heart disease (severe arrhythmia, heart attack)?

Do you suffer from kidney insufficiency or other kidney diseases?

Do you suffer from severe circulatory disorders, thrombosis, or embolism?

Do you suffer from severe varicose veins?

Do you suffer from skin damage such as open wounds, bacterial infections, or poorly healed surgical scars?

Do you suffer from a thyroid dysfunction?

I confirm that the information provided above is accurate. My data will be treated confidentially in accordance with Zehm Dental's Terms & Conditions and Privacy Policy.

I have read the General Terms and Conditions and the Privacy Policy and accept their validity.

I acknowledge that appointments must be canceled at least 24 hours in advance and that a cancellation fee may be charged in accordance with the Terms and Conditions in the event of late cancellation or a no-show.

Signature *