Date ________________

Name and surname of the patient ________________________

Phone number _____________________
Age ________________

Please answer the questions listed below. (Circle the appropriate answer). This
questionnaire is necessary for proper treatment planning. Privacy is protected.
1. Do you have allergies or adverse reactions:
a) on local anesthesia. ------------------------------------------ Yes No I do not know
b) on antibiotics. -------------------------------------------------- Yes No I don't know
c) on food, plants, fur. ------------------------------------------ Yes No I don't know
d) on latex (rubber). --------------------------------------------- Yes No I don't know
e) on chlorine. ---------------------------------------------------- Yes No I don't know
f) on alcohol. ----------------------------------------------------- Yes No I don't know
2. You have or have had heart or cardiovascular diseases:
a) Heart disease, angina attack, stroke. ---------------- Yes No I don't know
b) high or low blood pressure. ------------------------------ Yes No I don't know
c) cardiac arrest or shunting. ---------------------------------- Yes No I don't know
3. You have diabetes. ------------------------------------------ Yes No I don't know
4. You have asthma. ---------------------------------------------- Yes No I don't know
5. You have hives. ------------------------------------------------ Yes No I don't know
6. You have had an epileptic attack. ---------------------------- Yes No I don't know
7. You have an eye disease. ------------------------------------ Yes No I don't know
8. Do you have an infectious disease:
A) Ivy. ----------------------------------------------------- Yes No I don't know
b) Hepatitis. ----------------------------------------------------- Yes No I don't know
c) tuberculosis. --------------------------------------------------- Yes No I don't know
d) Venous disease. ---------------------------------------------- Yes No I don't know
9. Do you take the following drugs:
a) hypotensive (pressure-lowering). --------------------------- Yes No I don't know
b) antihistamine (antiallergic). --------------------------- Yes No I don't know
c) Anticoagulants (thinning agents). ---------------------- Yes No I don't know
d) Antibiotics. ----------------------------------------------------- Yes No I don't know
10. You have had prolonged bleeding after tooth extraction, trauma or various
surgical manipulations. -------------------------------- Yes No I don't know
For ladies:
a) pregnancy. ----------------------------------------------------- Yes No I don't know
b) Lactation. ----------------------------------------------------- Yes No I don't know

Patient Signature -------------------------