Patient questionnaire

The questionnaire should be completed before visiting Unic Ortho Clinic.

Answering the following questions will allow the staff to significantly reduce the patient's registration time before the first consultation. The answers will be used during the visit for the dental examination and further diagnostics. Also, your doctor may ask additional questions. All information provided is covered by medical confidentiality and is for the sake of your safety. If you are unsure, please ask the registration desk before your scheduled appointment or the doctor during your consultation for clarification.

Patient questionnaire for adult

"* Required" oznacza pola wymagane

Patient questionnaire

The questionnaire should be completed before visiting Unic Orto Clinic. Answering the following questions will allow the staff to significantly reduce the patient's registration time before the first consultation.

The answers will be used during the visit for the dental examination and further diagnostics. Also, your doctor may ask additional questions. All information provided is covered by medical confidentiality and is for the sake of your safety. If you are unsure, please ask the registration desk before your scheduled appointment or the doctor during your consultation for clarification.

First name and surname* Required

First name Surname

PESEL

Birth date* Required

Residence address* Required

Address City Postal code

Correspondence address

Different than residence address

Correspondence address

Address City Postal Code

Phone No.* Required

E-mail* Required

DENTAL HISTORY AND PATIENT EXPERIENCE

Who referred you to the appointment (doctor's name):

How did you find out about our clinic?

Previous Dentist:

How long have you been his patient? (state in months or years)

Date of last dental visit:

Date of last oral x-ray:

How would you rate the condition of your oral cavity?* Required

excellent

good

not bad

weak

Determine from 1(weak) to 10 (very strong) your fear of dental treatment:

What is the main goal and desire to start treatment?

HEALTH e.g.: very well and permanently healed teeth

IMAGE e.g.: health and a beautiful aesthetic smile

COMFORT e.g.: health and comfort improvement

Are there any possible treatment challenges?

TIME e.g.: lack of time or desire for quick treatment

FINANCES e.g.: financial constraints, specific budget, treatment spread over time

Fear, e.g.: past experience, fear of discomfort

What is the motivation for starting and completing treatment?

HIGH - I want it very much

LOW - I'm not fully decided yet

Are you satisfied with your smile?* Required

Yes

If not, what would you change?

Have you had any unpleasant experiences or complications related to dental treatment?* Required

Yes

Have you ever had a tooth extraction?* Required

Yes

Have you ever worn fixed braces, undergone orthodontic treatment or bite correction?* Required

Yes

Have you ever experienced problems with anesthesia or reaction to anesthesia?* Required

Yes

GENERAL MEDICAL HISTORY

Please answer the following questions.

Do you feel healthy?* Required

Yes

Have you been treated in a hospital in the past 2 years?* Required

Yes

Are you currently being treated for anything?* Required

Yes

If so, for what?

Are you taking anticoagulants or aspirin:* Required

Yes

If so, when?

Chronic, what kind?

In the past 3 months, what kind?

What medications/injections are you taking:* Required

Chronic, what kind?

In the past 3 months, what kind?

I don't take at all

If so, which ones?

Are you allergic to anything?* Required

Yes

If so, for what?

Do you experience:

shortness of breath

urticaria

swelling

itching

Have you ever experienced problems with anesthesia or reaction to anesthesia?* Required

Yes

If so, for what?

Are you prone to bleeding?* Required

Yes

Do you have episodes of fainting or unconsciousness?* Required

Yes

Do you have a pacemaker or artificial heart valve?* Required

Yes

Do you have or have you had any of the following diseases:

Heart diseases (myocardial infarction, coronary artery disease, heart defect, heart rhythm disorders, myocarditis)

Yes

Other cardiovascular diseases (hypertension, low blood pressure, syncope, shortness of breath)

Yes

Vascular diseases (varicose veins, phlebitis, poor blood circulation in the limbs, pain in the lower extremities when walking)

Yes

Diseases of the digestive system (gastric ulcer, duodenal ulcer, intestinal diseases)

Yes

Lung diseases (emphysema, pneumonia, tuberculosis, asthma, chronic bronchitis)

Yes

Urinary tract diseases (nephritis, kidney stones, difficulty urinating)

Yes

Metabolic disorders (diabetes, gout)

Yes

Thyroid diseases (hyperthyroidism, hypothyroidism, goitre, Hashimoto's disease)

Yes

Diseases of the nervous system (epilepsy, paresis, loss of consciousness, paralysis, sensory disorders, myasthenia gravis)

Yes

Diseases of the osteoarticular system (root pain, degenerative changes in the spine or joints, conditions after fractures, rheumatoid arthritis RA, osteoporosis)

Yes

Blood and coagulation diseases (hemophilia, anemia, tendency to hemorrhages, nosebleeds, prolonged bleeding after tooth extraction)

Yes

Eye diseases (glaucoma)

Yes

Infectious diseases:

infectious hepatitis A

infectious hepatitis B

infectious hepatitis C

AIDS

tuberculosis

venereal diseases

Fibromyalgia

Yes

Alcoholism

Yes

Change of mood (depression, neurosis)

Yes

Other ailments, what kind?

What was the last blood pressure measurement?

Have you been operated on before?* Required

Yes

If so, for what reason?

Have you had a blood transfusion?* Required

Yes

If so, when and for what reason?

Do you smoke tobacco/cigarettes?* Required

Yes

If so, how much per day and since when?

The following questions and consumption of alcohol or other drugs within the past 48h are critical for effective pain relief and safe therapy.

Do you drink alcohol?* Required

Yes

If so, how much per week on average (give volume)?

Do you use sedatives, sleeping pills, drugs?* Required

Yes

If so, which ones?

Do your gums bleed or feel pain when you floss and clean your teeth?* Required

Yes

Have you ever undergone treatment for gum disease or been told that there has been bone loss around your teeth?* Required

Yes

Are there people in your family who have undergone periodontal disease?* Required

Yes

Have you ever experienced gum recession?* Required

Yes

Have you ever had a spontaneous loosening of a tooth (not caused by trauma), or does eating apples make it difficult for you?* Required

Yes

Have you experienced a burning sensation in your mouth?* Required

Yes

Have you ever noticed an unpleasant taste or odor from your mouth?* Required

Yes

TOOTH STRUCTURE

Have you experienced any tooth tissue loss in the past 3 years?* Required

Yes

Do you feel that there is too little saliva in your mouth, or do you experience difficulty swallowing food?* Required

Yes

Do you feel holes (e.g., depressions, openings) on the biting surfaces of the tooth?* Required

Yes

Do any of your teeth show sensitivity to heat, cold, biting, sweets, or do you avoid brushing any part of your teeth?* Required

Yes

Are there cavities, grooves or chips near the gum line of teeth?* Required

Yes

Have you ever had a broken or chipped tooth, or a toothache or cracked filling?* Required

Yes

Does food often get between your teeth?* Required

Yes

OCCLUSION AND TEMPOROMANDIBULAR JOINT

Do you have problems with your spine (e.g., after an accident) or temporomandibular joints (pain, sound when moving, limited range of opening, locking, crackling)?* Required

Yes

When you clench your teeth, do you have the feeling that your jaw is being pushed backwards?* Required

Yes

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars or other types of hard, dry food?* Required

Yes

Has there been a change in your teeth in the past 5 years, such as shortening, reduction in thickness, or wear?* Required

Yes

Have your teeth become more crooked, reduced the distance between them, or begun to overlap?* Required

Yes

Has there been an enlargement of the spaces between teeth or has there been loosening of teeth?* Required

Yes

Do you have to do more than one closure, compression or misalignment of the mandible to make the upper and lower teeth fit together?* Required

Yes

Do you chew ice, bite your nails, use your teeth to hold objects, or have other similar habits?* Required

Yes

Do you clench your teeth or do anything else during the day that causes them pain?* Required

Yes

Do you have sleep problems (e.g., sleep apnea, anxiety), wake up sleep-deprived, or with a particular sensation when it comes to your teeth?* Required

Yes

Do you wear or have you worn bite splints in the past?* Required

Yes

Do you place your tongue between your teeth or close your teeth over your tongue?* Required

Yes

SMILE CHARACTERISTICS

Would you like to change anything about the appearance of your teeth?* Required

Yes

Have you ever had your teeth whitened?* Required

Yes

Have you experienced any discomfort or awareness about the appearance of your teeth?* Required

Yes

Have you ever been disappointed with the outcome of previously performed dental work?* Required

Yes

QUESTIONS REGARDING WOMEN

Are you pregnant?

Yes

If so, how many months?

When was your last period?

Are you using oral contraceptives?

Yes

Date of questionnaire completion:

Patient's name and surname:

Patient questionnaire

The questionnaire should be completed before visiting Unic Ortho Clinic.