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Patient Information(confidential)
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*Title :
*First Name :
Middle Name :
*Last Name :
*Nationality :
* Date Of Birth :
(DD/MM/YY)
Marital status :
Address :
*Contact Number (mobile or landline number)
Mobile :
Home/Work :
Email :
How did you find us ?
internet
advertising
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friends
family
others
 
If Other Please Specify
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Dental History
   
*Reason for this visit ?
How often do you visit the Dentist?
What Would you like us to do today?
Are you in dental discomfort today?
Yes No
Date of last dental visit?
(DD/MM/YY)
What was done then?
Please check if you have had problems with any of the following:
Bad Breath
Food collection between teeth
Periodontal treatment
Bleeding gums
Grinding or clenching teeth
Sensitivity to sweets
Sensitivity to hot
Lose teeth or broken fillings
Sensitivity to cold
Sensitivity to biting
Sore or growth in month
Clicking or popping of jaw
Are you currently under physician care?
Yes No
If yes describe :
Have you been Hospitalized within the last 5 Years?
Yes No
If yes describe :
Women : Are you Pregnant?
Yes No
Taking birth control pills?
Yes No
Do you have any of the following disease or medical problems?
Hepatitis
Diabetes
Anemia
Cancer
High blood pressure
 
Allergies - Describe
 
Blood disease - Describe
 
Are you taking any drugs or medicine - If so, what?
   
 
 
 
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