Questionnaire to check the health condition before the treatment in the clinic

All questions also refer to the period of the past 14 days

If you will answer YES to any of the questions, FIRST CONSULT with your personal doctor or outpatient clinic by e-mail or telephone.

Please enter your details where you are available for easier time coordination and communication.








YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

The information below is important mainly for further actions. If you do not have any medications / allergies, leave the windows empty.








Copyright by Zobna ordinacija Anja Siegl, dr. dent.med. All rights reserved.