PREOPERATIVE QUESTIONNAIRE FOR ADULTS
Clinic:
--select a clinic--
AKADEMIA DENTYSTÓW Klinika Stomatologiczna w Grójcu
BESTDENT ul Przejazd 2 w Warszawie
BETTER Centrum Stomatologiczne ul. Kopernika 8/18 w Warszawie
B&B DENTAL CLINIC ul. Bartnicza 4a w Warszawie
CSME Centrum Stomatologii i Medycyny Estetycznej w Mińsku Mazowieckim
DENTALUX ul. Racławicka 131 w Warszawie
DENTAL CARE ROSZKOWSKI W. Andrzeja Szomańskiego 10a w Warszawie
DENTAL SERVICE CARE ul. Braci Wagów 4 w Warszawie
DENTAL DESIGN Klinika Stomatologiczna w Pruszkowie
DENTAL FRATERNITY Kliniki Stomatologiczne
DENTALIFE Centrum Stomatologiczne ul. Wiktorska 7/11 w Warszawie
DENTART Specjalistyczny Gabinet Stomatologiczny w Otrębusach
DENTIN Klinika Stomatologiczna w Markach
DENTISTREE Klinika Stomatologiczna w Wilanowie
DENTOKLINIKA Klinika Stomatologiczna ul. Świetlików 8 w Warszawie
DR FRANK Autorska Klinika Stomatologiczna ul. Bluszczańska 67/U3 w Warszawie
DUODENT Gabinet Stomatologiczny w Grodzisku Mazowieckim
E-DENT Gabinet Stomatologiczny w Pruszkowie
HOLDENT Gabinet Stomatologiczny ul. Berensona 13 w Warszawa-Białołęka
K&K DENT Gabinet Stomatologiczny ul. Wańkowicza 2/3a w Warszawie
KEN 50 STOMATOLOGIA gabinet ul. KEN 50 w Warszawie
STOMATOLOGIA KOBYŁKA Gabinet Stomatologiczny w Kobyłce
KONSTANCIN CLINIC Centrum Stomatologii w Konstancinie
KLINIKA ORDONA Dr A Lewandowski Stomatologia ul. Ordona 12a w Warszawie
MEDICOVER STOMATOLOGIA Kliniki w Warszawie
M-DENTAL MAŃKOWSCY w Białobrzegach
MIDENTIST Gabinet Stomatologiczny w Milanówku
MRMED Stomatologia Dziecięca ul. Janowskiego 50 w Warszawie
NIECKULA DENTAL CLINIC Stomatologia Wilanów w Warszawie
NIEWADA CLINIC Implantologia i Stomatologia w Wilanowie
NOWOLIPIE DENTAL CLINIC Klinika Stomatologiczna w Warszawie
ODENT Centrum Ortodoncji i Implantologii ul Duchnicka 3 w Warszawie
ODONTO Klinika Stomatologiczna w Warszawie
ORAVELLE CLINIC Stomatologia i Medycyna estetyczna ul. Solec 22 w Warszawie
PAN KROKODYL Stomatologia Dziecięca ul. Ząbkowska 23/25 w Warszawie
PERFEKT DENT Centrum Stomatologia i Ortodoncji Białołęka w Warszawie
PERIOMEDICA Klinika Stomatologiczna na Woli w Warszawie
PRODENTAL Klinika Stomatologiczna w Chotomowie
PROMED Klinika ul. Uniwersytecka 5 w Warszawie
SOLDENT Klinika Estetycznej Ortodoncji i Implantologii ul. Bagno 2 w Warszawie
SPECTRUM Irena Chodak Stomatologia ul. Nowolipie 7a w Warszawie
STOMATOLOGIA TOMASZ SAK Klinika Stomatologiczna ul. Romera 4b w Warszawie
STOMATOLOGIA NOWAK | WOŁCZ DENTAL CLINIC ul. Aleja Komisji Edukacji Narodowej 49/11 w Warszawie
SUPRADENT Klinika Stomatologii Estetycznej i Ortodoncji ul. Biały Kamień 1 w Warszawie
TWÓJ UŚMIECH Gabinet Stomatologiczny Ewa Pulik w Pruszkowie
UNION DENTAL Kliniki Stomatologiczne w Warszawie
YOUR DENTIST Gabinet Stomatologiczny ul. Grzybowska 2/32 w Warszawie
First name:
Last name:
PESEL / National ID number:
Date of birth:
Weight (kg):
Height (cm):
Gender:
--select--
Female
Male
Procedure / examination to be performed (type):
Patient's preferred appointment date:
City / Town:
Postal code:
Residential address:
Contact phone number:
Email address:
2. Detailed questionnaire
1. Have you ever been hospitalized? (If yes, for what reason and when?)
NO
YES
2. Have you ever undergone general anesthesia or any other type of anesthesia? (If yes, for what reason and when?)
NO
YES
3. Have you experienced any complications related to anesthesia?
NO
YES
4. Has anyone in your immediate family (parents, siblings, grandparents) experienced any complications related to anesthesia? (If yes, please specify.)
NO
YES
5. Does the patient have a disability? (If yes, please specify.)
NO
YES
6. Is the patient able to complete this questionnaire independently and provide informed consent for anesthesia?
NO
YES
7. Are you currently under the care of a psychologist or psychiatrist?
NO
YES
8. For what reason will the dental procedure be performed under general anesthesia?
9. Do you have any allergies? (If yes, please specify what you are allergic to, e.g. medications, foods, chemicals, animal dander, pollen, dust, mold, and what symptoms occur, e.g. skin reactions, hay fever, swelling, shortness of breath, anaphylactic shock.)
NO
YES
10. Have you been ill within the last 14 days? (Runny nose, cough, fever, diarrhea, vomiting, other.)
NO
YES
11. Are you currently taking any medications? If yes, please list them (including anticoagulants/blood thinners, weight-loss medications, and hormonal medications).
NO
YES
12. Do you suffer from motion sickness, postoperative nausea, or an exaggerated gag reflex?
NO
YES
13. Do you have any respiratory conditions? (Shortness of breath, asthma, COPD, emphysema, tuberculosis, sinusitis, other.)
NO
YES
14. Do you have high blood pressure (hypertension) or any other vascular disease?
NO
YES
15. Do you have any heart disease or a heart defect? (Chest pain, coronary artery disease, previous heart attack, heart failure, inflammation of the heart, valvular heart disease, other.)
NO
YES
16. Do you have any heart rhythm disorders? (Palpitations, atrial fibrillation, rapid heartbeat, tachycardia, bradycardia, heart block.)
NO
YES
17. Do you have a cardiac pacemaker, or have you ever undergone an ablation procedure?
NO
YES
18. Do you have any gastrointestinal problems? (Diarrhea, constipation, peptic ulcer disease, gastroesophageal reflux disease [GERD], liver disease, pancreatic disease, other.)
NO
YES
19. Do you have any kidney, urinary tract, or prostate conditions?
NO
YES
20. Do you have any musculoskeletal conditions? (Spinal conditions, bone fractures, inflammation, degenerative bone or joint disease.)
NO
YES
21. Do you have any muscle disorders or muscle weakness? (Myasthenia gravis, myopathy, other.)
NO
YES
22. Is there any history of muscle disease in your immediate family?
NO
YES
23. Do you have any neurological conditions? (Stroke, transient ischemic attacks [TIAs], weakness or paralysis, epilepsy, or any history of loss of consciousness, fainting, or seizures.)
NO
YES
24. Do you have any metabolic conditions? If yes, how are they treated? (Diabetes, hypoglycemia, obesity, porphyria, gout.)
NO
YES
25. Do you have any endocrine disorders? (Thyroid, adrenal gland, or pituitary gland disorders.)
NO
YES
26. Do you have any blood or bone marrow disorders? (Anemia, blood clotting disorders, tendency to have spontaneous nosebleeds, easy bruising, other.)
NO
YES
27. Do you have any eye conditions? (Glaucoma, cataracts, or use of contact lenses.)
NO
YES
28. Is there any possibility that you may be pregnant?
NO
YES
29. Do you have any loose teeth, removable or fixed orthodontic braces/appliances, or removable dentures?
NO
YES
30. Do you smoke cigarettes or use heated tobacco products or electronic cigarettes (e-cigarettes/vapes)?
NO
YES
31. Do you drink alcohol? (If yes, how often?)
NO
YES
32. Do you use recreational/illicit drugs? (If yes, please specify which substances and when you last used them.)
NO
YES
33. Do you currently have, or have you previously had, any other health problems not mentioned in the questions above? If yes, please specify.
NO
YES
Remarks and additional information:
I consent to the processing of my personal data for the purpose of keeping medical records.
*
I declare that I have read the information on preparing for anesthesia.
*
I declare that I have not withheld any important information regarding my health and that the information provided is true and complete.
*
Finish and submit the questionnaire
