"Implantologia ad alta qualità ma a basso costo con dentisti esperti ed affidabili."

Questionnaire about your health

If you have decided to obtain a quote from Best Dental Implants Online, we advise you to fill out this questionnaire about your health, so that the most suitable dental clinic and specialists for your case can prepare the best treatment plan for you. All the information provided are protected by medical confidentiality.

We value your email privacy and will never share your details. Privacy policy

First Name(s) (required)
Last Name (required)
Date of birth ( not required)

Questionnaire about your health

Do you have / did you have any of the medical conditions / diseases listed below? If yes and if necessary please write additional information.

1. Allergy (to what?)
2. Epilepsy
3. Respiratory diseases (which?)
4. Bleeding disorder
5. Diabetes (which type?)
6. Glaucoma (higher pressure int he eyes)
7. Hematologic diseases (diseases of blood producing organs)
8. Cardiovascular disease
8.1 Heart failure
8.2 Coronary heart disease / Angina pectoris
8.3Heart attack
8.4 Heart rhythm disturbances
8.5 Pacemaker
8.6 Valvular heart disease / - compensation
8.7 Hypertension (high blood pressure)
8.8 Hypertension (low blood pressure)
8.9 Hypo perfusion of the CNS/Apoplexy
9. Infections
9.1 Hepatitis
9.2 AIDS
10. Liver diseases
11. Gastro-intestinal diseases
12. Kidney disease
12.1 Chronic renal failure
12.2 Dialysis
13. Osteoporosis
14. Rheumatoid arthritis
15. Thyroid diseases
16. Tumor diseases
17. Previous operations (which?)
18. Are you afraid of the treatment?
20. Are you pregnant?
21. Do you take any medication? (all regularly taken ones, even Aspirin) (required)
22. Do you smoke? (if yes, how much/day) (required)

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Best Dental Solutions LtD. 22 200 503 805

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