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Juureravi - Microstyle OÜJuureravi - Microstyle OÜ
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Preliminary information form

Please fill in the following form so that we can make our services safer for you. As accurate answers as possible to the following questions are important for planning your treatment. Your answers will be kept confidential.

General health condition

1. Do you take any medications regularly?
2. Do you have any sensitivity or allergy to any substances?
(For example: penicillin, aspirin, iodine, latex)
4. Do you smoke?
5. Do you have any of the following conditions? (Please indicate all past and current conditions)
6. Do you have a pacemaker, a prosthetic heart valve, or joint prostheses?
7. Do you take bisphosphonates, or have you undergone chemotherapy or radiation therapy?

Symptoms

1. Are you currently experiencing pain symptoms?
2. Can you identify which tooth hurts?
4. Did the symptoms appear suddenly?
Frequency
Pain character
Does anything relieve the pain?
Does anything make the pain worse?
Do you have sensitivity to:
Does pressing on the gum next to the tooth cause pain?
Does changing body position (tilting your head) cause tooth pain?
During the last 30 days, have you had pain or stiffness in your jaw upon waking?
6. Has this tooth recently had any restorations placed on it (filling or crown)?
7. Has root canal treatment been started or performed on this tooth?
8. How did you hear about our clinic?