Understandable

Secure

Easy

Real signature on mobile phone, tablet or PC

DSGVO compliant

No local saving of the PDF

PDF password protected

PDF is sent encrypted

Multilingualism

Note: Where should the demo anamnesis sheet be sent to? To test the demo for the anamnesis sheet, please enter an e-mail address. The anamnesis sheet will be sent to this e-mail address and encrypted with the password demo.

Where should the demo medical history sheet be sent to?

E-mail address of the recipient

Medical history sheet

Personal information

Salutation

First name

Last name

Date of Birth

Post Code

City

Street

Contact information

Mobile

Telephone

E-mail

Gender

Insurance

Additional insurance

Blood Thinner (ASS, Markumar, Heparin, Equilis)

Yes No

Bisphosphonates (Zometa®, Fosamax®)

Yes No

Cardiovascular Disorders (Pacemaker, Heart Attack, Blood Pressure)

Yes No

Stroke (Apoplex)

Yes No

Allergies and Sensitivities

Yes No

Lunge Disorders (Asthma, COPD, Chronic Bronchitis)

Yes No

Metabolic Disorders (Diabetes, Kidneys, Liver, Gastrointnstinal, Thyroid)

Yes No

Nerve Disorders (Epilepsy, Multiple Sclerosis, Parkinson’s)

Yes No

Pregnant / Breast Feeding

Yes No

Blood Disorders (Hemophilic, Anemic)

Yes No

Infectious Diseases (Hepatitis, TBC, HIV, AIDS)

Yes No

Chemotherapy, Radiotherapy

Yes No

Mental Health (Depression, Bulimia, etc.)

Yes No

Recall / Would you like an appointment reminder by post or e-mail?

Yes No

Orthodontic Therapy

Yes No

Gum Disease (Bleeding Gums, Gingivitis, Periodontitis)

Yes No

Jaw joint complaints (pressing, crunching, muscle tension)

Yes No

Online demo Medical history sheet (Using example dental practice)

Fill out the medical history form conveniently and easily online

Where should the demo medical history sheet be sent to?

Medical history sheet

Personal information

Contact information

General Medical History Questions and Answers

Dental History Questions and Answers

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