CITY OF ESPOO ANAMNESIS FOR DENTAL HEALTH CARE

Section of Social and Health Services Confidential

Oral Health Care 2008
Surname (also former)

Forenames Identity number

Street address

Postal code Post office

Profession Employer

Telephone home Telephone to the office

Why do you need treatment?

Earlier dental health care in Where?

Are you pregnant? Estimated date of delivery

Yes No
Have you had serious troubles caused by local anesthesia?
No Yes, which?
Are you allergic to any medicine or other stuff (e.g. penicillin, aspirin, rubber, any foodstuff)?
No Yes, which?
Do you smoke regularly?
No Yes, how many?
Are you in good health?
Yes No
Please tick the diseases or symptoms you have or have had
Cardiovascular disease Stomach ulcer Regular medication:
Pacemaker, artificial heart Kidney disorders Which?
valve Liver disease, hepatitis
High blood pressure HIV infection
Blood disease, anemia Epilepsy
Bleeding disorder Recurrent headache
Diabetes Psychiatric disease
Rheumatoid arthritis Other general disease,
Rheumatic fever which?
Joint prosthesis, vascular No regular medication
prosthesis
Thyroid disease
Lung disease, asthma
Attending physician

Further information

Information according to the Personal Data Act (523/1999):

Your personal data is recorded in our client register. The personal data is confidential and is only given based on the law or your
permission. The file description and information about your right to check your data and correct it is available for you at our
dental clinics.
Do you permit us to give information about your care to the dental health care or other health care?
(Act on the Status and Rights of Patients No. 785/92)
Yes No
Date Signature