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You are here: DentaTurism > Estimation request

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Name *

Birthday *

Email *

Phone number including country code *

Town *

Country *

My problem *

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MY DENTAL CHART

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Dental History

1. Are you presently having dental pain? Yes No

2. Have you had orthodontic treatment? Yes No

3. Do your gums bleed when brushing your teeth? Yes No

4. Have you ever been told you have pyorrhea (gum disease)? Yes No

5. Have you ever had any gum treatments? Yes No

6. Have you ever had professional instructions on dental home care? Yes No

7. Do you have any pain or soreness around the eyes or ears? Yes No

8. Do you have any unpleasant odor or taste in your mouth? Yes No

9. Do you always have something to be treated or repaired when you visit a dentist? Yes No

10. Do you feel that in the past you have required a lot of dental work? Yes No

11. If yes, was it to replace previous dentistry? Yes No

12. Do you wish to talk with the dentist privately about any problem? Yes No

Medical chart

Have you ever had any of the following? Allergies
Arthritis, Gout or sore joints
Artificial joint replacement
Blood trouble, anemia, leukemia
Chest pain, pressure or tightness
Cancer
Diabetes
Excessive bleeding
Fainting, convulsions, epilepsy
Glaucoma
Headaches when lying down
Heart attack
Heart murmur
Hepatitis, liver desiease, jaundice
High blood pressure
History of drug or alcohol abuse
Lung Trouble (TB, asthma, emphysema)
Mitral valve prolapse
Nervous breakdown, psychotherapy
Positive HIV test
Radiation treatments
Rheumatic fever
Shortness of breath
Swelling of ankles or feet
VD (syphillis, gonorrhea, etc.)
Problems with recreational drugs
Problems with local anesthesia
I'm pregnant, or trying to get
I'm nursing a baby
I'm using birth control pills or patches

Additional comments

Do you have any other problems that we should know about? Do you have any additional concerns or comments ?

TRAVEL ORGANIZATION

Desired treatment period

No. of persons

Accomodation Villa Astoria**** Hotel Oscar*** Other

Rooms Double Single Suites

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