QUESTIONNAIRE FOR PATIENTS WHO HAVE BOOKED AN APPOINTMENT

IMPORTANT:

This questionnaire is intended only for patients who have already booked an appointment with us. If you have an upcoming visit at the clinic, we kindly ask you to complete the questionnaire below to help us prepare for your appointment in the best possible way

Patient Information Form

"*" indikerer påkrævede felter

Dette felt er til validering og bør ikke ændres.

Date*

DD skråstreg MM skråstreg ÅÅÅÅ

Reason for enquiry

When was your last dental visit?*

Name*

First name Lastname

Address*

Street address City Postal code

Email*

Telephone number*

Have you booked an appointment?*

Yes

Are you a member of “danmark”?*

Yes

Which group?*

Have you been a member for more than 5 years?*

Yes

Do you have dental insurance?*

Yes

Date of birth*

Are you currently employed?*

Yes

Current dentist

Why would you like to change dentist?*

How would you like to be contacted for your regular check-ups?*

E-mail

SMS

Do you have sensitive teeth?*

Yes

Do your gums bleed when brushing?*

Yes

Do you have tooth pain?*

Yes

Do you experience discomfort when lying down during treatment?*

Yes

Would you like local anaesthesia for drilling, even if the nerve is not affected?*

Yes

Do you have any issues with local anaesthesia?*

Yes

Do you smoke?*

Yes

Are you pregnant?*

Yes

Do you have a heart condition?*

Yes

Do you have any implants, bypass surgery, or artificial joints?*

Yes

Do you have dental implants?*

Yes

Do you have diabetes?*

Yes

If yes – what type of diabetes?*

Do you have high blood pressure?*

Yes

Do you have epilepsy?*

Yes

Do you have anaemia?*

Yes

Do you have asthma, hay fever, or allergies?*

Yes

Do you have infectious liver disease (hepatitis)?*

Yes

HIV?*

Yes

Have you previously had surgery in the heart, neck, or head?*

Yes

Have you previously received penicillin treatment?*

Yes

Have you experienced complications with penicillin?*

Yes

Do you have prolonged bleeding or take blood-thinning medication?*

Yes

Have you received radiation therapy?*

Yes

Are you being treated with corticosteroids?*

Yes

Are you taking medication for neurological conditions?*

Yes

Are you receiving any other medical treatment??*

Yes

If you are receiving other treatment, please specify which medication.*

Have you had orthodontic treatment?*

Yes

Have you considered improving the appearance of your teeth?*

Yes

Would you like to replace old amalgam (silver) fillings?*

Yes

Do you use any tools to clean between your teeth?*

Yes

If yes – what do you use?*

Dental floss

Toothpicks

Other

Are you comfortable visiting the dentist?*

Yes

Do you attend regular dental check-ups?*

Yes

If yes – how often do you attend dental check-ups?

If no – please let us know why and whether you are interested in regular dental check-ups

Have you had teeth removed, including wisdom teeth?*

Yes

If yes – which ones?*

Upper left

Lower left

Upper right

Lower right

When did you last have X-rays taken of your teeth?

Are there any special considerations we should be aware of?*

Yes

If yes – please specify which considerations.*

Why did you choose our clinic?*

Found online

Recommendation

Other

Who recommended us? Please provide a name or your relationship to them.*

Please let us know how you found us*

Consent*

I accept the privacy policy and hereby give my consent for Tandlægerne v/Runddelen to store and process my personal data, access my medical records via FMK (sundhed.dk), communicate with my health insurance, and exchange relevant information with healthcare professionals and public/private institutions as required.

Nørrebro

Nørrebrogade 148

2200 København N

Tlf. 35 83 00 33

Læs mere om klinikken på Nørrebro her

Østerbro

Dag Hammarskjölds Allé 19 1. tv.

2100 København Ø

Tlf. 35 83 00 33

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Telefon*

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