Medical history - Dentistry

Fill in the fields and send off the form by e-mail. You will sign the completed form upon arrival.

The application form is confidential and secured. All the personal data and medical information are confidential and shall be used exclusively for the purpose of treatment and administrative records.

Please fill in all fields marked with *

Title*
First name*
Surname*
Date of birth*
Street*
City*
Post code*
E-mail address
Telephone/fax*
Mobile phone
I consent to my personal data and medical documentation (including examination and X-ray results) being used for the purpose of treatment.

Next of Kin contact details:

Title
First name
Surname
Street
City
E-mail address
Telephone/fax
Mobile phone

Do you have or have you ever had	YES	NO	If your answer is "YES",  please specify
Heart disease
Blood vessels disease
High blood pressure( how long)
Myocardial infarction ( when)
Shortness of breath and fatigue caused by effort
Swelling of legs, feet or ankles
Bleeding tendency
Allergies (what kind)
Asthma
Diabetes
Lung diseases
Neurological diseases
Do you take any drugs?
Epilepsy
Do you take hormonal contraceptives?
Rheumatic diseases
Jaundice, liver inflammation (what kind)
AIDS
Are you allergic to antibiotics?
Are  you allergic to anaesthetics?
Pregnancy
Smoking
Kidney diseases
Gastric diseases
Ear inflammation
Headaches
Sinus pain
Teeth grinding
X-ray treatment
Bleeding gums
Dry mouth
Mouth breathing
Misaligned bites
New cavities occur quickly
Under/over bites: palate, cheeks, tongue
Undergone surgeries
All the information concerning my health condition provided herein is true. I consent to the above information being used for the purpose of treatment.