Personal data

In order to perform an assessment of your health status, please send us a panoramic dental x-ray in .jpg format or fill in the table below. Within 48 hours we'll provide you the assessment.

Please fill in the table below:

Dental history

Do you currently have dental pain? Yes
Have you been under dental treatment? Yes
Do your gums bleed when brushing? Yes
Have you been diagnosed with pyorrhea (gum disease)? Yes
Have you ever had gum treatment? Yes
Have you ever received specialized advice regarding teeth care at home? Yes
Do you suffer from painful or sore ears or eyes? Yes
Does your mouth have an unusual smell or taste? Yes
When you see the dentist, do you always have to have something treated or fixed? Yes
As far as you can tell, do you think that you needed a lot of medical care for your teeth? Yes
If you selected yes above, was that in order to replace the previous teeth? Yes
Do you wish to talk privately to the dentist about your health issues? Yes

Have you ever suffered from any:


Arthritis, gout or weak joints

Artificial replacements of the joints

Blood problems, anemia or leukemia

Chest pain, pressure or strain



Excessive bleeding

Fainting, convulsion, seizure


Headaches when lying horizontally

Heart attack

Cardiac murmur

Hepatitis, liver disease, jaundice

Blood pressure

Alcohol or drug abuse

(TB, asthma, emphysema)

Mitral valve prolapse

Nervous breakdown, psychotherapy

Positive HIV test

Radiation therapy


Breathing difficulty

Swollen legs or ankles

Dermatology and venereal diseases (syphilis, gonorrhea)

Local anesthetic incidents

Pregnancy or trying to get pregnant

Breast feeding

On birth control pills


More than 20 cigarettes

Antidepressant treatment


Other information
Do you have any other problems that we should be aware of?
Do you have any other comments or questions?