Health questionnaire MKG Hamm and Implant Center Hamm First name / last name of the patient* Date of birth day month year* Dentist / Doctor Do you have family insurance? If yes, please mark with a cross YES Main insured person First name / Last name Date of birth Day Month YearContact details Street and house number* Postcode / Place of residence* Mobile phone* Landline E-mail address* Phone relativeInsurance Private insurance / supplementary insurance Basic rate of private insurance Does the following apply to you? If yes, please mark with a cross Blood thinners Blood thinners / coagulation disorders Marcumar ASS Aspirin Eliquis Plavix Godamed Pradaxa Xarelto Diseases & pregnancy Kidney diseases Heart disease (heart valve, heart attack, stent, endocarditis) Liver diseases Osteoporosis / Bisphosphonates Lung diseases HIV HEP Pregnancy Allergies to: Penicillin Clindamycin Ibuprofen Novalgin more allergies List of allergies: Medication other important medications List of medications:Signature and consent Place of completion* date Please sign here with the mouse or your finger *I certify that I have correctly and completely declared all illnesses, health issues, risk factors and medications known to me *I agree that my next of kin, listed below, may complete missing information, obtain appointment information and make or change appointments, as well as obtain diagnostic information Relatives Spam protection question*: What color is grass? I have read the privacy policy and agree to ! Fields marked with * are mandatory and must be filled in!
