Language
English (US)
Bulgarian
Medical History Form
GREEN LANES DENTAL
Full Name
*
First Name
Last Name
What is your gender?
*
Please Select
Male
Female
N/A
Date of birth
*
-
Day
-
Month
Year
Date
Contact Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
When was your last visit for dental examination and professional cleaning?
*
Check the conditions that apply to you or any member of your immediate relatives:
*
No
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
*
No
Chest
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
How many cigg a day? How long have you used/been using them?
Do you consume alcohol?
*
Please Select
Yes
No
How many units alcohol a day
Signature
*
SIGN IN THE LOWER HALF
Date
*
-
Day
-
Month
Year
Date
Save as PDF and SEND to GREENLANESDENTAL@YAHOO.COM
Continue
Continue
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