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Cabinet dentaire Dr. Strukan

Before your first appointment

Medical questionnaire

About ten minutes. Your answers go straight to the practice and are read by the dentist before your appointment.

Medical questionnaire

Fields not marked “optional” are required.

01About you

Sex(optional)

At least one number, so that we can reach you.

For example CNS.

02Do you have any of the following conditions?

  • Allergies

  • Heart disease

  • High blood pressure (hypertension)

  • Blood clotting disorder or blood thinners

  • Poor circulation

  • Heart rhythm disorders (arrhythmia)

  • Infectious diseases

  • Diabetes

  • Organ transplant

  • Radiotherapy

  • Chemotherapy

  • Osteoporosis

  • Epilepsy

  • Hospital stay in the last 12 months

  • Do you take any medication?

  • Drug intolerance

  • Smoker

  • Pregnancy

  • Thyroid disorders

  • Liver disease

  • Kidney disease

  • Gastrointestinal disease

  • Respiratory disease

  • Rheumatic fever

  • Physical or mental disability

03Are you currently experiencing any of the following?

  • Toothache

  • Bad breath (halitosis)

  • Bleeding gums

  • Receding gums

  • Pain in the jaw joints

  • Pain in the chewing muscles

  • Snoring

  • Teeth grinding

  • Headaches

  • Fear of the dentist

04Are you wearing, or have you worn, any of the following?

  • Full or partial denture

  • Crown or bridge

  • Implant treatment

  • Braces

  • Splint (e.g. a night guard)

A rough date is enough, for example “spring 2024”.

05Anything else?

For example a condition that is not on the list, or a reaction to an anaesthetic.

06Terms and signature

  • In certain cases, additional fees are charged for treatments marked as personal convenience (CP = convenance personnelle), including aesthetic fillings, root canal treatment and periodontal treatment. These additional fees are not reimbursed by your statutory health insurance. Some treatments may, however, be partly refunded by the Caisse Médico-Chirurgicale Mutualiste (CMCM).
  • If you are unable to keep your appointment, please cancel it at least 24 hours in advance. Otherwise, the costs will be charged to the insured person in full.
  • Medical confidentiality obliges us to fully respect the legal framework for the protection of personal data, and Regulation (EU) 2016/679 (the General Data Protection Regulation, GDPR) is fully respected. To provide the best possible care, we may need to pass your information on to third parties such as the CCSS (Centre commun de la sécurité sociale), your statutory health insurance (for example the CNS) or others. Your data are protected and are only shared where this is appropriate for your care or required to meet our legal obligations.
  • You can access your personal data and have it corrected at any time. We kindly ask you to let us know at least 48 hours in advance.
  • Your personal data are only stored for as long as data protection rules permit.
  • All practitioners fully respect the Code of Medical Ethics in force in Luxembourg (Code de déontologie médicale).

Date

Signature

Sign inside the box with your mouse, finger or a stylus.

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