Dental Clinic

Home
E-consultation
Medical Tourism
Services
Reservation
Blog
Contact
AR

Δ

Medical Form

First Name

Last Name

Email

Phone/Mobile

Dental Complaints

Bad breath ?

Yes

No

Bleeding gums?

Yes

No

Clicking / painful / popping jaw ?

Yes

No

Food collection between teeth ?

Yes

No

Grinding teeth ?

Yes

No

Loose tooth or broken fillings ?

Yes

No

Periodontal treatment ?

Yes

No

Sensitivity to hot/cold/sweets ?

Yes

No

Sensitivity when biting ?

Yes

No

Sores or growths in your mouth Appearance ?

Yes

No

Medical History

Arthritis, Rheumatism

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Back Problems

Yes

No

Blood Disease

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Circulatory Problems

Yes

No

Cough, Persistent

Yes

No

Diabetes ( Type I / II )

Yes

No

Epilepsy

Yes

No

Fainting

Yes

No

Glaucoma

Yes

No

Headaches

Yes

No

Heart Problems

Yes

No

Hemophilia

Yes

No

Hepatitis ( A / B / C )

Yes

No

Scarlet Fever

Yes

No

Skin Rash

Yes

No

Stroke

Yes

No

Swelling of Feet or Ankles

Yes

No

Thyroid Problems

Yes

No

Tobacco Habit ( smoking / chewing )

Yes

No

Tuberculosis

Yes

No

Ulcer

Yes

No

Venereal Disease

Yes

No

High Blood Pressure

Yes

No

HIV/AIDS

Yes

No

Jaw Pain

Yes

No

Kidney Disease

Yes

No

Liver Disease

Yes

No

Mitral Valve Prolapse

Yes

No

Pacemaker

Yes

No

Pregnant

Yes

No

Radiation Treatment

Yes

No

Respiratory Disease

Yes

No

Rheumatic Fever

Yes

No

ALLERGIES:

Aspirin

Yes

No

Codeine

Yes

No

Local Anesthetic

Yes

No

Penicillin

Yes

No

Sulfa

Yes

No

Latex

Yes

No

Other

Yes

No

LIST MEDICATIONS: List medications you are currently taking:

DISCLAIMER:

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Date / Time

Signature