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- Medical History Form

Patient Medical History Form

Home - Patient Medical History Form

Patient Medical History Form

If you have any of the following , please mark

Radiation Therapy

Lack or loss of body hair

Bone Disease

Osteoporosis

Heart murmur

Heart Attack, Surgery

Difficulty in swallowing

Difficulty,pain on urination

High & low blood pressure

Rheumatic, scarlet fever

Pain, pressure in chest

Swollen painful joints

Frequent sore throat

Muscle pain

Abdominal pain

Depression

Parasthesias,numbness

Dizziness, fainting

Excessive urination

Blood in sputum

Wheezing, asthma

Venereal disease

Thyroid trouble

Shortness of breath

Pigmentations

Prosthetic joints

Double vision

Tuberculosis

Hearing loss

Excessive thirst

Drooping of eyelid

Frequent nosebleeds

Blood in urine

Weight change

Frequent headaches

Nervous breakdown

Blood transfusion

Ulcers

Hoarseness

Cough

Jaundice

Hepatitis

Diabetes

Vertigo

Anemia

Leukemia

Sinusitis

Glaucoma

AIDS

Cancer

Spontaneous Itching & Rashes

Smoking

Spontaneos Bruising

Mitral Valve

Prolapse

Are you allergic to or have you adversely reacted to Medicines if any please specify *

Local Anesthetics (Novacaine)

Penicillin or other Antibiotics

Barbituates, Sedatives, Sleeping Pills

Sulfa Drugs

Aspirin

Other Drugs if any please specify

Other Drugs if any please specify do you have habit of clenching or grinding your teeth conciously or during sleep

Yes

No

what is the present state of your oral condition ?

Completely Missing Teeth in both the jaws

Completely Missing Teeth in upper jaw

Partially Missing teeth in both the jaws

Partially Missing Teeth in upper jaw

Partially Missing Teeth in lower jaw

What services are you intersted in? Message here

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Select Required Dental Treatment for Consultation *

Root Canal Treatment

Dental Implant

Smile Makeover

Teeth Whitening

Third Molar Extraction

Gum/Periodontal Therapy

Other Dental treatment

Full Mouth Fixed teeth with Dental Implants

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Dr. Darshana Khairnar
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+91 9028197536
precisiondentalimplant@gmail.com
104, Aadarsh Society, RTO Lane, opp. siddharth banquet, Near Kokilaben Ambani Hospital, Andheri West, Maharashtra - 400053, INDIA

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