Date:27-07-2017
Patient No:New Registration
Doctor:
Ref No:Pr_New Registration

Personal Information (Confidential)
*First Name :
*Last Name :
Age:
Gender :
Address :
City :
Country :
* Phone :
Email :
Doctor :
   


Dental History
Date of last dental visit?
Treatment taken for last visit?
How often do you visit the Dentist?
Reason for this visit?
Please check if you had problems with any of the following :
Bad breath
Lose teeth or broken fillings
Sensitivity to hot / cold
Periodontal treatment
Bleeding Gums
Sore or growth in mouth
Grinding for clenching teeth
Clicking or popping of jaws
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
Did you have any allergies?
Yes No
If yes describe :
Did you have any blood related disease?
Yes No
If yes describe :
Are you taking any drugs or medicine?
Yes No
If yes describe :