PREOPERATIVE QUESTIONNAIRE FOR CHILDREN
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
Child's first name:
Child's last name:
PESEL / National ID number:
Child's date of birth:
Weight (kg):
Height (cm):
Gender:
--select--
Girl
Boy
Procedure / examination to be performed (type):
Patient's preferred appointment date:
City / Town:
Postal code:
Residential address:
Parent's / guardian's phone number:
Guardian's email address:
2. Child's medical history
1. Has the child ever been hospitalized? (If yes, for what reason and when?)
NO
YES
2. Has the child ever undergone general anesthesia? (If yes, for what reason and when?)
NO
YES
3. Has anyone in the child's immediate family (parents, siblings, grandparents) experienced any complications related to general anesthesia? (If yes, please specify.)
NO
YES
4. Does the patient have a disability? (If yes, please specify the type.)
NO
YES
5. For what reason will the dental procedure be performed under general anesthesia?
6. Is the child afraid of blood tests, blood draws, or injections?
NO
YES
7. Does the child have any allergies? (If yes, please specify what the child is allergic to, e.g. medications, foods, cosmetics, animal dander, pollen, dust, mold, and what symptoms occur, e.g. skin reactions, hay fever, swelling, shortness of breath, anaphylactic shock.)
NO
YES
8. Has the child been ill within the last 14 days? (Runny nose, cough, fever, diarrhea, vomiting, other.)
NO
YES
9. Is the child currently taking any medications?
NO
YES
10. Is the child currently under the care of a psychologist or psychiatrist?
NO
YES
11. Does the child suffer from motion sickness or have an exaggerated gag reflex?
NO
YES
12. Does the child have any ear, nose, or throat (ENT) conditions? (Tonsillitis, enlarged adenoids, ear infections, other.)
NO
YES
13. Does the child have any respiratory conditions? (Shortness of breath, asthma, frequent bronchitis, laryngitis, other.)
NO
YES
14. Does the child have, or has the child ever had, a heart defect or any other heart condition? (e.g. heart rhythm disorders, other.)
NO
YES
15. Does the child have any gastrointestinal problems? (Diarrhea, vomiting, gastroesophageal reflux disease [GERD], liver disease, other.)
NO
YES
16. Does the child have any kidney or urinary tract conditions?
NO
YES
17. Does the child have, or has the child ever had, any musculoskeletal conditions? (Spinal curvature, bone fractures, inflammation of the bones or joints.)
NO
YES
18. Does the child have any muscle disorders or muscle weakness? (Myasthenia gravis, muscular dystrophy, other.)
NO
YES
19. Is there any history of muscle disease in the child's family?
NO
YES
20. Has the child ever experienced loss of consciousness, fainting, seizures, epilepsy, or muscle weakness/paralysis?
NO
YES
21. Does the child have diabetes? (If yes, please specify how it is treated.)
NO
YES
22. Does the child have any endocrine disorders? (Thyroid, adrenal gland, or pituitary gland disorders.)
NO
YES
23. Does the child have porphyria?
NO
YES
24. Does the child have any blood or bone marrow disorders? (Anemia, blood clotting disorders, tendency to have spontaneous nosebleeds, easy bruising, other.)
NO
YES
25. Does the child have any loose teeth or removable or fixed orthodontic braces/appliances?
NO
YES
26. Does the child currently have, or has the child 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 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 child's health and that the information provided is true and complete.
*
Finish and submit the questionnaire
