мова-укр
About Us
Our treatment philosophy
Our team
Gallery
Makeovers
Porcelain veneers
About treatment
Teeth whitening
Tooth bonding — flow injection
Piezosurgery
DSD – Digital Smile Design — Digital smile analysis
Sandblasting teeth
Tooth reconstruction
Reinforcement of teeth — inlays
Laser — what can we treat with it?
Root canal treatment — painless and effective
Diagnostics — CBCT — Computed tomography
Prosthetics
Porcelain veneers
Porcelain crowns
Bridges
Prostheses
Air abrasion
ICON - Removal of white spots on the teeth
Dental surgery
The smile of a senior citizen
Invisalign — invisible orthodontics
Digital Crowns
Implants
Dental implants
Implantology consultation
Implant treatment options
Implant treatment procedure
Short implants
Immediate implants
Implant-supported prostheses
Osseointegration
A-PRF and I-PRF technique
After the procedure
Regeneration of the tissue
Bone regeneration
Regular check-ups
FAQ
Contraindications and risks
Procedure
Reviews
Price List
Contact
Quick contact
Contact us:
91 812 88 88
Szczecin - Podzamcze
ul. Wielka Odrzańska 31 b
Make an appointment or ask us a question via the
contact form
.
tel: 91 812 88 88
Menu
About us
Metamorphoses
Porcelain veneers
How we treat
Digital Crowns
Implants
Reviews
Price List
Contact
Quick contact
About us
Our treatment philosophy
Our team
Gallery
How we treat
Teeth whitening
Tooth bonding — flow injection
Piezosurgery
DSD – Digital Smile Design — Digital smile analysis
Sandblasting teeth
Tooth reconstruction
Reinforcement of teeth — inlays
Laser — what can we treat with it?
Root canal treatment — painless and effective
Diagnostics — CBCT — Computed tomography
Prosthetics
Air abrasion
ICON - Removal of white spots on the teeth
Dental surgery
The smile of a senior citizen
Invisalign — invisible orthodontics
Prosthetics
Porcelain veneers
Porcelain crowns
Bridges
Prostheses
Implants
Dental implants Szczecin
Implantology consultation
Immediate implants
Implant treatment options
Implant treatment procedure
Short implants
Implant-supported prostheses
Osseointegration
A-PRF and I-PRF technique
After the procedure
Regeneration of the tissue
Bone regeneration
Regular check-ups
FAQ
FAQ
Contraindications and risks
Implant procedure
Dental interview
Homepage
>
Dental interview
Name
Date of birth
Previous dentist
How long have you been his/her patient?
How would you rate the condition of your oral cavity:
Excellent
Good
Not bad
Poor
Approximate date of last treatment (other than teeth cleaning)
I visit the dentist regularly every:
3 months
4 months
6 months
12 months
Irregularly
WHAT IS CURRENTLY BOTHERING YOU?
PLEASE ANSWER THE FOLLOWING QUESTIONS:
PERSONAL INTERVIEW
1. Are you afraid of dental treatment? On a scale of 1 (not at all) to 10 (very much)
2. have you had unpleasant experiences at the dentist?
Yes
No
3. have you ever had complications as a result of previous treatment at the dentist?
Yes
No
4. Have you had any problems with local anesthesia?
Yes
No
5. Have you ever had braces, orthodontic treatment or a corrected bite?
Yes
No
6. have you had your teeth extracted?
Yes
No
GINGS AND BONE
7. Do your gums bleed or hurt when you use a toothbrush or floss?
Yes
No
8. Have you ever been treated for gum disease or been told you have bone loss around your teeth?
Yes
No
9. do you experience an unpleasant odor or taste in your mouth?
Yes
No
10. has anyone in your family had periodontitis?
Yes
No
11. do you ever experience receding (receding) gums?
Yes
No
12. have you ever had your teeth (or tooth) start to move on their own (without injury). Do you have difficulty eating an apple?
Yes
No
13. Do you experience a burning sensation in your mouth?
Yes
No
TEETH
14. have you had cavities in the past 3 years?
Yes
No
15. Do you seem to have little saliva in your mouth or experience difficulty swallowing any food?
Yes
No
16. Do you feel or notice holes (e.g., pits) on the biting surface of your teeth?
Yes
No
17. are any of your teeth sensitive to: hot, cold, biting, sweets:
hot
cold
chewing
sweets
Do you avoid cleaning any part of your mouth? Which one?
Yes
No
18. Do you have fissures or indentations on your teeth at the gum line (known as cervical cavities)?
Yes
No
19. Have you ever had a toothache, broken filling, broken, chipped or cracked tooth?
Yes
No
20. Do you collect food between your teeth?
Yes
No
BITE AND TEMPOROMANDIBULAR JOINT
21. do you have problems with the temporomandibular joint?
pain
crackling
limited opening
trismus
jumping
22. Do you feel like your lower jaw (mandible) is forced to move backward when you bring your upper and lower teeth together?
Yes
No
23. Do you avoid or have any problems with eating marshmallows, candy bars, etc. or chewing gum?
Yes
No
24. have your teeth changed in the last 5 years
have become shorter
crackling
thinner
damaged
grated
25. Have your teeth become:
tilted
crowded
thinner
overlapping
26. are your teeth loose or do gaps (spaces, gaps) appear between them?
Yes
No
27. do you have more than one "bite" and squeeze or move your teeth to make them fit together when joining upper and lower teeth?
Yes
No
28. do you habitually push your tongue between your teeth, press it against them or bite down on them?
Yes
No
29. do you bite your nails, pen, hold objects in your teeth, or have other oral habits?
Yes
No
30. Do you clench your teeth during the day or drive them to pain?
Yes
No
31. do you have trouble sleeping or wake up with a headache or a "weird feeling" about your teeth?
Yes
No
32. do you wear or have you ever worn a bite correction appliance?
Yes
No
SMILE
33. Is there anything about the appearance of your teeth that you would like to change?
Yes
No
34. Have you ever had your teeth whitened?
Yes
No
35. Have you ever felt embarrassed or ashamed about the appearance of your teeth?
Yes
No
36. do you feel disappointed with the appearance of the dental work previously performed?
Yes
No
I consent to the performance of dental procedures on me under local, superficial, infiltration and regional anesthesia, with violation of tissue continuity, using a needle.
I agree to be contacted for the purpose of providing medical services.
I consent to the processing of my personal data for the purpose of responding to this inquiry. Provision of data is voluntary, but necessary to process the inquiry. I have been informed of my rights: access to data, the possibility of rectification, deletion or restriction of processing, the right to data portability, to lodge an objection and the right to withdraw consent. The administrator of the personal data is Stomatologia na Podzamczu Sp. z o.o., based in Szczecin, 31b Wielka Odrzańska St., NIP 8513272127, REGON 521607813, KRS 0000963088. Read more about the
privacy policy
.
Dziękujemy! Otrzymaliśmy Twój formularz.
Upss coś poszło nie tak.Spróbuj ponownie.