Smart Clinic

Medical History

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Dear Patient

in addition to your personal details, we also need information about your medical health condition. This is important for your treatment. Your information of course will be kept secret according to medical confidentiality data protection.

Personal Details


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Health insurance

Heart diseases
* Heart failure
* Endocarditis
* Artificial heart valve
* angina pectoris
* Artificial cardiac pacemaker
* heart attack, when?

Vascular diseases
* Low blood pressure
* High blood pressure

Metabolic diseases
* Diabetes
* Gastrointestinal diseases
* Thyroid disorder

Bone diseases
* Osteoporosis
* Do/did you take Bisphosphonate?

Blood diseases
* Bleeding tendency (hemophilia)
* Anemia

Infectious diseases
* Hepatitis (B or C)
* Tuberculosis

Tumor diseases
* Irradiation in the head area
* Chemotherapy

Neurological diseases
* Epilepsy
* Stroke, When?

Allergy / intolerance
* Allergy / intolerance

Other diseases
* Glaucoma
* Asthma

Further information
* Are you pregnant? Pregnancy week if yes

* Do you smoke?
* Regular medication? Which?

I obologie my self
1. To tell about any changes prior to further treatment. 2. To meet one´s deadline or cancel in sufficient time (at least 24 hours before). Otherwise, the resulting costs (deficiency compensation) can be charged. I agree with the storage of my data. Furthermore, I consent to the transfer of data (x-rays, medical reports, findings) to my home dentist / doctor / referring physician. All patient data is transmitted exclusively encrypted. I have read, understood and accept the information on the collection of personal data (DSGVO).

Signature of the patient / guardian
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× Signature of the patient / guardian


× Acceppt the privacy