FISA ONLINE
NUME :
PRENUME :
DATA NASTERII :
SEX :
ADRESA :
TELEFON :
VA RUGAM SA COMPLETATI URMATORUL FORMULAR :
GREUTATE :
INALTIME :
OCUPATIE :
AVETI DURERI DENTARE IN ACEST MOMENT ?                                                        
VA ESTE TEAMA DE TRAMANETUL STOMATOLOGIC ?                                         
ATI AVUT EXPERIMENTE NEPLACUTE IN CABINETUL DENTAR ?                      
ATI FOST INTERNAT IN ULTIMII ANI ?                                                                         
ATI FOST TINUT SUB OBSERVATIE MEDICALA IN ULTIMII DOI ANI ?              
ATI EFECTUAT IN ULTIMII DOI ANI ANALIZE DE RUTINE?                                     
BENEFICIATI DE TRATAMENT MEDICAMENTOASE ?                                              

IN CAZUL IN CARE LUATI MEDICAMENT SPECIFICATI NUMELE ACESTORA:
ANTIBIOTICE                                                                                                                               
ANTIHIPERTENSIVE                                                                                                             
NITROGLICERINA                                                                                                                             
ANTIHISTAMINICE                                                                                                                
ANTICUAGULANTE                                                                                                                         
TRANCHILIZANTE                                                                                                                
ANTIALGICE                                                                                                                                                
DIGITALICE                                                                                                                             
INSULINA/ALTE ANTIDIABETICE                                                                                                  
ANCONCEPTIONALE                                                                                                          
ALTE MEDICACAMENTE                                                                                                              
HORMONI TIROIDIENI                                                                                                        
MENTIONATI CARE SUNT ACESTEA :

SUNTETI ALERGIC ?
SPECIFICATI TIPUL ALERGIEI :
ALIMENTARA                                                                                                                        
NEALIMENTARA ( PRAF, POLEN, INTEPATURI, INSECTE, LATEX )                   
MEDICAMENTOASE:
PENICILINA                                                                                                                           
SULFAMIDE                                                                                                                           
ASPIRINA                                                                                                                               
ALTE ANTIBIOTICE                                                                                                      
ERITROMICINA                                                                                                                   
ANESTEZICE ( XILOCAINA, NOVOCAINA )                                                         
CODEINA                                                                                                                             
ALTE SUBSTANTE :                                                                                                           

SUFERITI DE EPILEPSIE ?                                                                                                   
SUFERITI DE AFECTIUNI PRECUM :
NEVRALGII                                                                                                                            
PSIHOZA                                                                                                                                  
NEVROZA                                                                                                                                
SCHIZOFRENIE                                                                                                                    

SUFERITI DE BOLI RESPIRATORII ?           
ASTM 
BRONSITA 
TBC 
PNEUMONIE

SUFERITI DE AFECTIUNI ORL ?
RINITA 
SINUZITA 
ADENOIDITA 
AGMIGDALITA

AVETI PROBLEME DE COAGULARE A SANGELUI ?
SUFERITI DE DIABET ?
CE TIP :

SUFERITI DE BOLI HEMATOLOGICE ?
ANEMIE 
HEMOFILIE 
AGRANULOCITOZA 
LEUCEMIE 
TROMBOCITOPONIE

SUFERITI DE BOLI CARDIACE SAU AFECTIUNI CIRCULARE ?
INSUFICIENTA CARDIACA 
ANGINA PECTORALA 
TULBURARI DE RITM CARDIAC 
PACE MAKER 
MALFORMATII CARDIACE CONGENITALE 
ISCHEMIE CEREBRALA AVC 
PROTEZA VALVULARA 
HIPERTENSIUNE ARTERIALA 
HIPOTENSIUNE ARTERIALA

SUFERITI DE BOLI INFECTIOASE ?
ATI EFECTUAT TESTUL HIV IN ULTIMELE SASE LUNI ?
HEPATITA TIP A 
HEPATITA TIP B 
HEPATITA TIP C 
SIDA 

SUFERITI DE BOLI HEPATICE ?
CIROZA
ICTER

AVETI PROBLEME DIGESTIVE ?
GASTRITA 
ULCER 
COLECISTA 
COLITA 
PANCREATITA

SUFERITI DE AFECTIUNI URO-GENITALE ?
INSUFICIENTA RENALA 
DIALIZA 
CISTITA NEFRITA 
BOLI CU TRANSMITERE SEXUALA

SUFERITI DE OSTEOPOROZA?
SUFERITI DE ARTRITA REUMATOIDA ?
AVETI PROBLEME HORMONALE ?
DACA DA  DE CE FEL ?

AVETI AFECTIUNI TUMORALE ?
DACA DA  DE CE FEL ?

ATI BENEFICIAT DE TRATAMENTE CHIRURGICALE ?
ATI URMAT TRATAMENT RADIO TERAPEUTIC?
ATI URMAT TRATAMENT CHIMIO TERAPEUTIC?
PENTRU FEMEI - SUNTETI INSARCINATA ?

SUNTETI LA MENOPAUZA ?
MOMENTUL INSTALARI ACESTUIA :

SUNTETI DEPENDENT DE DROGURI?
DACA DA  DE CE FEL ?

ATI MAI URMAT TRATAMENT STOMATOLOGIC ?
CAND ? DIN CE MOTIV ?

CUNOASTETI RISCURILE ANESTEZIEI DENTARE ?
( LEZIUNI VASCULARE, LEZIUNI NERVOASE, NECROZA MUCOASEI, FACTURI ALE ACULUI, INGHITIREA SAU ASPIRAREA ACULUI, INTOXICATII SISTEMICE, REACTII DE HIPERSENSIBILITATE SAU ALERGICE, REACTII ADVERSE DATE DE VASOCONSTRICTOR )

CUNOASTETI RISCURILE TRATAMENTULUI ENDODONTIC ?
( ANASTEZIE INCOMPLETA, PERFORATII ALE CAMEREI PULPARE, PERFORATII RADICULARE, REACTII ADVERSE LA DIVERSE SUBSTANTE, IRITATII TISULARE LOCALE, REACTII NEURO TOXICE, OPTIRATII DE CANAL INCOMPLETE, OPTURATII DE CANAL CU DEPASIRE, FACTURARE RADICULARA )

DACA NU VA SUNT CUNOSCUTE ACESTE RISCURI VA RUGAM SA CERETI MEDICULUI INFORMATII DESPRE ACESTEA.

DECLAR TOATE ACESTE DATE CORESPUNZATOARE REALITATI SI SUNT DE ACOR CU EFECTUAREA TRATAMENTULUI STOMATOLOGIC. IN CAZUL IN CARE APAR MODIFICARI IN PRIVINTA STARII MELE DE SANATATE SAU A MEDICATIEIMA OBLIG SA INFORMEZ MEDICUL STOMATOLOG.
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