Turkish Dental Association Health History Form

Eliz Dent - Implant and Cosmetic Dentistry / Turkish Dental Association Health History Form

Turkish Dental Association Health History Form

Name*

Patient’s

Name

Surname

Occupation*

Birth Date*

Phone

Country*

Are you now under the care of a physician? Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Please mark (X) your response to indicate if you have had any of the following diseases or problems

Cardiovascular disease

Diabetes

High or Low blood pressure

Contagious Disease

Epilepsy

Febrile Rheumatism

Arthritis

Thyroid Problems

Abnormal Bleeding

Drug Allergies

Sexual transmitted disease

Hepatitis, jaundice or liver disease

Asthma, bronchitis

Kidney Problems

Gastrointestinal disease

Sinus trouble

AIDS or HIV infection

Osteoporosis

Cancer /Chemotherapy / Radiation Treatment

Do you use tobacco (smoking, snuff, chew, bidis)? If yes, How many cigarettes do you smoke in a day?

Are you allergic to any medicines?

Have you had radiotherapy to the head and neck region?

Does the bleeding last long after surgery or injury?

Have you had a serious illness, operation, or been hospitalized?

Women Only Pregnancy? If yes, number of weeks? Nursing ?

Confirmation*

I certify that I have read and understand the above and the information given on this form is accurate.

I have read and accept the information text on the Protection and Processing of Personal Data.

Turkish Personal Data Protection

This field should be left blank

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