dent form

Contact form

DENTAL HISTORY FORM


Today's date:
Name, Surname:
Address:
Phone number:
Date of Birth:
Gender:

PATIENT'S DENTAL HISTORY:
Required treatment:
When was your last dental check-up:
Do you have any pain or discomfort now? What:
Do your gums bleed?
Have you ever had any surgery performed on your gums?
Have you ever had Root Canal Treatment?
Have you ever worn braces?
Do you wear dentures?
Do you grind your teeth?
Have you ever had any trauma to your mouth or face?
How often do you floss?
How often do you brush your teeth?

Please choose only one, correct answer.

Have you ever had anesthesia?
Have you ever had any problems with anesthesia?
Had anybody in your family had problems with anesthesia?
Are you being treated with any medicines?
If so, please specify:
Are you allergic to any medicines?
If so, please specify:
Have you been treated with steroids?
If so, please specify:
Do you have an allergy?
If so, please specify:
Do you have any blood pressure changes?
Does obfuscation or fainting happen to you?
Have you ever had problems with your heart?
If so, please specify:
Do you get breathless easily?
Do you suffer from asthma or bronchitis?
Do you smoke?
Have you ever had epileptic convulsions?
Do you suffer from any blood related diseases (HIV, AIDS etc.)?
If so, please specify:
Does heavy bleedings or easy bruises happen to you?
Have you had infectious jaundice?
DO you suffer from diabetes?
Do you often take sleeping pills or sedatives?
Are you pregnant?
Do you have a peacemaker?
Do you suffer from glaucoma?
Do you suffer from hypothyreosis / hyperthyreosis?
Do you suffer from rheumatoid arthritis?
I certify that the above questions were answered accurately and the best to my knowledge. I understand that providing the incorrect information can be dangerous to my health.