Smiles Turkey | Smiles Survey

Patient Pre-Consultation Questionnaire

TREATMENT RISK ASSESSMENT

Patient Pre-Consultation Questionnaire

Please answer all questions. All fields are required.

Contact Information
GENERAL HEALTH

1. Do you have diabetes or any blood sugar regulation problems? *

2. Do you have any autoimmune disease or chronic inflammatory condition? *

3. Have you had previous dental treatments that failed or required revision? *

4. Are you taking any medications that may affect healing? (e.g., steroids, bisphosphonates) *

5. Do you have any allergies to medications, anesthetic agents, or antibiotics? *

6. Have you ever experienced a bleeding disorder or clotting problem? *

7. Are you currently taking blood thinners? *

8. Do you have any condition that affects your immune system? *

9. Do you have a chronic illness that requires regular medical supervision? *

10. Do you have any heart condition? *

11. Have you ever had an angiogram or a heart stent placed? *

12. Do you have high blood pressure (hypertension)? *

13. Do you have kidney disease or kidney failure? *

14. Have you ever been diagnosed with cancer? *

15. Have you undergone any major surgery in the past? *

16. Do you have any prosthetic joints or devices in your body? (e.g., hip, knee) *

17. Do you have any plates, metal, or surgical implants in your body? *

18. Are you currently taking any regular medications? (e.g., blood thinners, blood pressure medications) *

19. Are you pregnant or is there a possibility you may be pregnant? *

SMOKING & LIFESTYLE

20. Do you smoke or vape? *

21. Alcohol consumption: *

22. Stress level in daily life: *

ORAL & DENTAL HISTORY

23. History of gum disease or bone loss? *

24. Tooth grinding or clenching (bruxism)? *

25. Bite problems or jaw discomfort? *

26. Previous cosmetic dental work? *

EXPECTATIONS & BEHAVIOUR

27. Importance of aesthetics compared to function: *

28. Expectation level: *

29. Willingness to follow post-treatment instructions: *

30. Patience with timelines and adjustments: *

31. How would you like your treatment to be explained? *

COMMITMENT & DECISION STYLE

32. Number of clinics contacted so far: *

33. Primary decision factor: *

34. Comfort with structured processes and approvals: *

35. Willingness to attend follow-ups if required: *

36. Do you have a timeframe in mind to start your treatment? *

37. Have you been to Turkey before? *

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