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Date of filling: 26.10.2021 16:45:42 (appears automatically)

Child’s gender

Please read the following document:

Patient questionnaire (covid-19)

1. Have you and your child been in isolation or self-isolation for the last 14 days before visiting the clinic?

2. Were there any close contacts over the past 14 days with a person under the supervision due to COVID-19, who subsequently become ill?

3. Were there any close contacts over the past 14 days with a person who was diagnosed with a laboratory confirmed COVID-19?

4. Have you and your child visited a clinic or medical centre where patients are tested for COVID-19?

5. Have you and your child experienced one or more symptoms in the last 14 days?

6. Have you tested for COVID-19?

Result of the last testing


Child health questionnaire

2. Allergy (medications, food, others)?

How is it manifested?

3. Blood type:

rhesus factor:

4. Does your child have any chronic diseases listed below?

5. Is your child registered by a neurologist?

6. Does your child suffer from seizures, fainting, dizziness

7. Prolonged bleeding after cuts

8. Diabetes

9. Does your child take any medications

10. Did your child have a head injury

11. Hepatitis A (Botkin's disease)

Hepatitis B, C

12. AIDS, sexually transmitted diseases

13. Periodically occurring oral ulcers, herpes

14. Bruxism (night teeth gnashing)

15. Sinus maxillary disease

16. Has your child had any previous negative dental treatment experiences


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