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
Medical interview
Homepage
>
Medical interview
PLEASE INFORM US IN THE FUTURE OF ANY CHANGE IN HEALTH HISTORY AND MEDICATIONS TAKEN
Name
Date of birth
Last general examination
Reason
Overall health rating:
Excellent
Good
Not bad
Poor
DO YOU NOW HAVE OR HAVE YOU EVER HAD YES
1. hospital treatment due to illness/injury
Yes
No
2. Adverse reaction to:
aspirin, ibuprofen, paracetamol, codeine
penicillin
tetracycline
erythromycin
sulfonamides
local anesthetics
fluoride
metals (nickel, gold, silver, others)
rubber
other (what kind?)
3. heart problem or cardiac stent (last 6 months)
Yes
No
4. history of infective endocarditis
Yes
No
5. artificial heart valve or corrected heart defect (PFO)
Tak
No
6. pacemaker or implantable defibrillator
Yes
No
7. artificial prosthesis (heart or joint valve)
Yes
No
8. acute arthritis or scarlet fever
Yes
No
9a. High pressure
Yes
No
9b. Low blood pressure
Yes
No
10. stroke / you are taking blood-thinning drugs)
Yes
No
11. anemia or other blood disorders
Yes
No
12. prolonged bleeding due to a minor cut (INR>3.5)
Yes
No
13. emphysema, sarcoidosis
Yes
No
14. tuberculosis
Yes
No
15. asthma
Yes
No
16. breathing or sleep problems (e.g., snoring, sinus problems)
Yes
No
17. kidney disease
Yes
No
18. liver disease
Yes
No
19. jaundice
Yes
No
20. parathyroid gland disease or calcium deficiency
Yes
No
21. hormone deficiency
Yes
No
22. high cholesterol or taking a statin
Yes
No
23. type I diabetes
Yes
No
Type II
Yes
No
24. gastric or duodenal ulcer
Yes
No
25. digestive disorders (e.g., gastric reflux)
Yes
No
26. osteoporosis/osteopenia (e.g., taking Bisphosphonates)
Yes
No
27. arthritis (arthritis)
Yes
No
28. glaucoma
Yes
No
29. contact lenses
Yes
No
30. head or neck injuries
Yes
No
31. epilepsy, epileptic seizures (epilepsy)
Yes
No
32. neurological problems (attention deficit disorder)
Yes
No
33. viral infections and herpes
Yes
No
34. any swelling or lumps in the mouth
Yes
No
35. hives, skin rash, hay fever
Yes
No
36. venereal diseases
Yes
No
37. hepatitis (type ...............)
Yes
No
38. HIV/ AIDS
Yes
No
39. tumor, abnormal growth
Yes
No
40. treatment with radiation
Yes
No
41. chemotherapy
Yes
No
42. emotional problems
Yes
No
43. psychiatric treatment
Yes
No
44. antidepressant medications
Yes
No
45. alcohol or drug addiction
Yes
No
PLEASE ANSWER IF:
46. you are currently being treated for any other diseases
Yes
No
47. you see a change in your overall health
Yes
No
48. you take medication to maintain your weight
Yes
No
49. you take dietary supplements
Yes
No
50 You often feel exhausted or fatigued
Yes
No
51 You are prone to frequent headaches
Yes
No
52 You smoke cigarettes or have smoked in the past
Yes
No
53 You are considered an irritable person
Yes
No
54 You are often unhappy or get depressed
Yes
No
55. you are taking contraceptives (FEMALE)
Yes
No
56. you are pregnant (WOMAN)
Yes
No
57. you have a prostate disorder (MALE)
Yes
No
Describe your current or any other treatment, or any upcoming surgeries that may affect your dental treatment.
Provide a list of any medications, supplements, or vitamins you have taken in the past two years.
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
I agree to have dental procedures performed on me under local, superficial, infiltrationand wire anesthesia, with violation of tissue continuity, with the use of 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.