Patient’s General Information

Full Name (required)

Date of birth (dd/mm/yyyy)

Telephone number (required)

E-mail (required)


Attach your file

Attach your file

Attach your file


Medical History

1- Are you under any medical treatment at this time?

2- Have you had side effects to any drugs including penicillin?

If yes, specificy

3- Has your doctor informed you that you suffer from?:
    a) Heart disease?
     b) High blood pressure?
     c) Respiratory Diseases?
     d) Diabetes?
     e) Rheumatic fever?
     f) Rheumatism or arthritis?
     g) Tumors or abnormal lumps?
     h) Any blood disease?
     i) Any liver disease?
     j) Any kidney disease?
     k) Any stomach or intestinal disease?
     l) Any venereal disease?
     m) AIDS?
     n) Yellow jaundice or hepatitis?

4- Are you taking any medications at this time?

If yes, what are you taking?

5- Are you in good general health at this time?

If not please explain

6- Some wounds have healed slowly or presented any complications?

7- Are you pregnant or breastfeeding?

8- Do you have a history of fainting?

9- Have you ever had X-ray treatments?

10- Any other comments

Patient’s Dental History

1- Do you have pain in or near your ears?

2- Do you have any injury or swelling around your mouth?

3- Have you experienced any swelling or pain in your mouth?

4 Does it hurt somewhere in your mouth when tight?

5- Have you ever had local anesthesia?

6- Have you had any reaction or allergic symptoms to local anesthesia?

7- Have you had a difficult tooth extractions in the past?

If yes please specify

8- Have you had a prolonged bleeding after a tooth extraction in the past?

9- Do your gums bleed?

10- Do you know the right method to brush your teeth?

11- Do you chew only on one side of the mouth?

If yes please specify

12- Do you have any dental discomfort at this time?

If yes please specify

13- Do you clean your teeth regularly during the day and night?

14-When was taken your last dental panoramic radiography?

15- Do you smoke?

16- Does any part of your mouth hurts when pressed or ingest irritants? (Cold, sweet, hot sauce, etc.)

If yes please specify