Date of filling: 21.12.2024 22:07:17 (appears automatically)
Clinic of planned treatment Kokshetau, Auelbekova Street 129/20 Uralsk, Ikhanova Street 52 Atyrau, Kulmanova Street 1 (Grand Atyrau Residential District) Ust-Kamenogorsk, Nursultan Nazarbayeva Ave. 29/23 Almaty, Kabanbai Batyra Street 122A Almaty, Rozybakiyeva Street, 105 B Almaty, Sholokhova Street 15 Nur-Sultan, Saraishyk Street 5, VP11 Nur-Sultan, Abay Ave. 28 Nur-Sultan, Kazhymukana Street 12
Child’s gender male female
Please read the following document:
1. Have you and your child been in isolation or self-isolation for the last 14 days before visiting the clinic? Yes No
2. Were there any close contacts over the past 14 days with a person under the supervision due to COVID-19, who subsequently become ill? Yes No
3. Were there any close contacts over the past 14 days with a person who was diagnosed with a laboratory confirmed COVID-19? Yes No
4. Have you and your child visited a clinic or medical centre where patients are tested for COVID-19? Yes No
5. Have you and your child experienced one or more symptoms in the last 14 days?
increased body temperature over 37.5C
cough (dry or with a small amount of sputum)
shortness of breath
fatigue
feeling of stuffiness in the chest
myalgia - muscle pain
I and my child experienced none of the symptoms listed above
6. Have you tested for COVID-19? Yes No
+ -
I understand that the provision of false information is a violation of the law in sanitary and epidemiological welfare of the population and it entails corresponding responsibility.
1. Last visit to the dentist
2. Allergy (medications, food, others)? Yes No
runny nose,
urticaria,
cough,
sneezing,
swelling,
Quincke's oedema
first (I),
second (II),
third (III),
fourth (IV))
rhesus factor:
positive,
negative
4. Does your child have any chronic diseases listed below? Heart (angina pectoris, shortness of breath)
Kidney
Liver
Gastrointestinal tract
Lungs
My child doesn’t have any of the listed diseases
5. Is your child registered by a neurologist? Yes No
6. Does your child suffer from seizures, fainting, dizziness Yes No
7. Prolonged bleeding after cuts Yes No
8. Diabetes Yes No
9. Does your child take any medications Yes No
(please, specify)
10. Did your child have a head injury Yes No
11. Hepatitis A (Botkin's disease) Yes No Hepatitis B, C Yes No
12. AIDS, sexually transmitted diseases Yes No
13. Periodically occurring oral ulcers, herpes Yes No
14. Bruxism (night teeth gnashing) Yes No
15. Sinus maxillary disease Yes No
16. Has your child had any previous negative dental treatment experiences Yes No
Please, provide any additional information about the health status of your child:
I sincerely answered to all questions in this questionnaire
I understand that only in the case of mandatory preventive examinations (1 time in 6 months) you can count on a certain period of treatment results, prosthetics.
I know that in the case of my child taking medications before visiting a dentist, I should inform the doctor about this.
I have been notified that before a doctor's appointment, my child needs to take a blood test for a Microreaction, according to the Decree of the Ministry of Health of the Republic of Kazakhstan # 312 of 23 May 2011, Appendix 1.
