test

Surname and first name:
Second name:
Address:
Phone number:
Email address:
PESEL number:

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1. When was the last time you visited a dentist?

2. What is the reason for your visit today?
Powód wizyty

3. What are your expectations of dental treatment?
Oczekiwania

4. how did you find out about us?
From a friendFrom the internetI walked pastOn the recommendation of another doctor

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5. do you smoke cigarettes? State how many a day:

6. When was the last time you had an X-ray performed?

7. do you have trouble biting or chewing?
NotYes

8. do you have trouble opening your mouth wide?
NotYes

9. Do you clench your teeth during the day and feel their pain?
NotYes

10. Do you hear "crackling" in your ears when opening your mouth or eating?
NotYes

11. Do you use or have you ever used a bite-protective splint?
NotYes

12. Have you had your teeth treated orthodontically?
NotYes

13. Have you had problems with your nasal sinuses?
NotYes

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**Disease:**
Respiratory systemKidneyRheumaticNervous systemEndocrine disruptionBloodNeurologicalThe digestive systemOsteoporosisOphthalmologyDiabetesEpilepsyPregnancyOther

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**Allergies and other information:**
Do you have a drug allergy?
Are you taking any medication?
Is there anything else you would like to inform the doctor about?
Dodatkowe informacje

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**RODO consents:**.
I consent to the processing of my personal data.

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