Anamnez Formu

Your Name

Patient’s Name:

Surname:

Occupation:

Country:

Birth Date

1. 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)?

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

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

4. Are you allergic to any medicines?

5. Have you had radiotherapy to the head and neck region

6. Does the bleeding last long after surgery or injury?

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

8.Women Only

Pregnancy? If yes, number of weeks?

Nursing ?

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

Signature

Date

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