Medical Questionnaire
Please tell us your health condition in detail.
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Mail Adress *
Today *
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Name *
Date of birth
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Mobile phone Number *
Home or Office phone number
Address *
Occupation *
How should we contact you? *
How did you find out us? (Multiple answers allowed) *
Required
What are your symptoms?(Multiple answers allowed) *
Required
When did you go to the Dentist last time? *
Do you have any allergy?(Multiple answers allowed) *
Required
What illnesses have you had in the past?(Multiple answers allowed) *
Required
Are you currently taking medication?(Multiple answers allowed) *
Required
Are you currently taking supplement? *
Have you ever been scared or bad feeling during dental treatment? *
What is your preference for treatment?(Multiple answers allowed) *
Required
What kind of treatment do you want ?(Multiple answers allowed) *
Required
What time is better to come?(Multiple answers allowed) *
Required
Treatment Policy(Multiple answers allowed) *
Required
Are you interested in "healthy life program" Dental checkup??(you can know the plan and cost through whole body and mouth checkup)
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Have you ever travel abroad in the past 14 days? *
Did you have a chance to see who travel abroad in the past 14 day? *
Is the person living together isolated or having a cold? *
Did you join the Event or meeting over 50 people in the past 1 month? *
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