Preoperative questionnaire

Preoperative questionnaire:

Name:
Your patient ID (see quote or e-mail)
Date of Birth
Address:
Telephone:
Email:
Health security number::
Surgery you would like to have:
Date you would like to come:
 / 
 / 
Have you already contacted a specialist about this surgery:
Were there any counter-indications for dental implant placement?
Your last tooth extraction was:
Do you have radicular dental cysts?
Do you regularly drink alcohol , if yes how often?
Do you smoke?:
Have you had or do you have a heart problem?
Have you had or do you have vascular issues?
Have you had or do you have brain problems?
Are you a diabetic?
Have you had or do you have lung problems? (asthma, respiratory failure…)
When you cut yourself, do you scar easily?
Are you following a course of medical treatment at the moment?
If YES, specify the name of the medicines:
Do you take drugs? (If yes, what type)
Are you a carrier of contagious disease? HIV, Hepatitis etc…:
Have you already been hospitalized?
Do you feel pain or an acute feeling in the right arm or in the chest area when you do a physical activity?
Do you sometimes have swollen feet?
Have you already had phlebitis?
Is your blood pressure normal?
Do you often suffer from vomiting?
Do you have allergies?
Notes:
Before your dental surgery:
You should not smoke the day of the intervention
You should wear comfortable clothes
You should not wear make-up.
You should follow you prescription. You need to take your antalgics in order to take them after the intervention.
It is important that you have eaten before the surgery. You take your usual breakfast without drinking much coffee or tea.
Take your usual medicines, unless contrary instructions.
DO NOT TAKE ASPIRINE OR OTHER BLOOD THINNER AT LEAST 10 DAYS PRIOR TO THE INTERVENTION.
Follow oral instructions that will be given to you.
Know that local surgery is not disabling and won’t restrain your usual activities. However, we advise you not to do any intensive physical activity during 48 hours after the intervention.
We stay at your disposal for any complimentary information.


I am informed of preoperative instructions and conditions:

Share:Email this to someoneTweet about this on TwitterPrint this pageShare on Google+Share on Facebook