Date of filling: 24.04.2024 19:54:48 (appears automatically)
Clinic of planned treatment Kokshetau, Auelbekova Street 129/20 Uralsk, Ikhanova Street 52 Atyrau, Kulmanova Street 1 (Grand Atyrau Residential District) Ust-Kamenogorsk, Nursultan Nazarbayeva Ave. 29/23 Almaty, Kabanbai Batyra Street 122A Almaty, Rozybakiyeva Street, 105 B Almaty, Sholokhova Street 15 Nur-Sultan, Saraishyk Street 5, VP11 Nur-Sultan, Abay Ave. 28 Nur-Sultan, Kazhymukana Street 12
Gender male female
Please read the following document:
1. Have you been in isolation or self-isolation for the last 14 days before visiting the clinic? Yes No
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? Yes No
3. Were there any close contacts over the past 14 days with a person who was diagnosed with a laboratory confirmed COVID-19? Yes No
4. Have you visited a clinic or medical centre where patients are tested for COVID-19? Yes No
5. Have you experienced one or more symptoms in the last 14 days?
Increased body temperature over 37.5C
Cough (dry or with a small amount of sputum)
Shortness of breath
Fatigue
Feeling of stuffiness in the chest
Myalgia - muscle pain
I experienced none of the symptoms listed above
6. Have you tested for COVID-19? Yes No
+ -
I understand that the provision of false information is a violation of the law in sanitary and epidemiological welfare of the population and it entails corresponding responsibility.
1. Last visit to the dentist
2. Allergy (medications, food, others)? Yes No
runny nose,
urticaria,
cough,
sneezing,
swelling,
Quincke's oedema
first (I),
second (II),
third (III),
fourth (IV)
резус-фактор:
positive,
negative
4. Do you suffer from diseases listed below? Heart (angina pectoris, shortness of breath)
Kidney
Liver
Gastrointestinal tract
Lungs
I don't have any of the listed diseases
5. Working pressure
Do you suffer from: high blood pressure Yes No
low blood pressure
6. Do you suffer from seizures, fainting, dizziness Yes No
7. Prolonged bleeding after cuts Yes No
8. Diabetes Yes No
9. Do you take any medications Yes No
(please, specify)
10. Did you have a head injury Yes No
11. Hepatitis A (Botkin's disease) Yes No Hepatitis B, C Yes No
12. AIDS, sexually transmitted diseases Yes No
13. Periodically occurring oral ulcers, herpes Yes No
14. Bruxism (night teeth gnashing) Yes No
15. Sinus maxillary disease Yes No
16. Do you use addictive drugs Yes No
17. Do you smoke Yes No
18. For women: Pregnancy Yes No
period
Please, provide here any additional information about your health
I sincerely answered to all questions in this questionnaire
I understand that only in the case of mandatory preventive examinations (1 time in 6 months) you can count on a certain period of treatment results, prosthetics.
I know that in the case of taking medications before visiting a dentist, I should inform the doctor about this.
I have been notified that before a doctor's appointment, I need to take a blood test for a Microreaction, according to the Decree of the Ministry of Health of the Republic of Kazakhstan # 312 of 23 May 2011, Appendix 1.
