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

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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

(Turkish) Eliz Diş

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(Turkish) Hekimlerimiz

Dr. Fatih KOZAN
Dr. Furkan BAŞAK
Dr. Beril DEMİR KARAMANLI
Dr. Erenay ALPAYÇETİN
Dr. Kerim Çakır

(Turkish) Hizmetlerimiz

Implant
Cosmetic Dentistry
Root Canal Treatment
Fillings
Jaw Surgery
Orthodontics
Pedodontics

(Turkish) Blog

Diş Eti Çekilmesi Neden Olur? Nasıl Düzelir?
Diş Sızlaması Neden Olur? Nasıl Geçer?
Diş Törpüleme Nedir? Nasıl Yapılır?
Gece Plağı Nedir? Nasıl Kullanılır?
Diş Beyazlatma Nedir? Yöntemleri Nelerdir?

The content of the page is for informational purposes only. Consult your dentist for diagnosis and treatment Site içeriğinde bulunan bilgiler bilgilendirmek içindir. Bu bilgilendirme kesinlikle hekimin hastasını tıbbi amaçla muayene etmesi veya tanı koyması yerine geçmez.
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