Medical History Form

This request form is strictly confidential and as such all personal data and medical information contained therein shall be used exclusively for the purpose of treatment and administrative records.

A * required field


0. Login to the Customer Center

1. Personal information

* Title:
* First name:
* Surname:
* Date of birth:
* Street:
* City:
* Country:
* E-mail address:
* Post code:
Telephone/fax:
Mobile phone:


2. Medical History Form

Do you have or have you ever had:		"YES"	"NO"	If your answer is "YES", please specify
Heart disease:
Blood vessels disease:
High blood pressure (how long):
Myocardial infarction (when):
Shortness of breath and fatigue caused by effort:
Swelling of legs, feet or ankles:
Bleeding tendency:
Allergies (what kind):
Asthma:
Diabetes:
Lung diseases:
Neurological diseases:
Do you take any drugs?:
Epilepsy:
Do you take hormonal contraceptives?:
Rheumatic diseases:
Jaundice, liver inflammation (what kind):
AIDS:
Are you allergic to antibiotics?:
Are you allergic to anaesthetics?:
Pregnancy:
Smoking:
Kidney diseases:
Gastric diseases:
Ear inflammation:
Headaches:
Sinus pain:
Teeth grinding:
X-ray treatment:
Bleeding gums:
Dry mouth:
Mouth breathing:
Misaligned bites:
New cavities occur quickly:
Under/over bites: palate, cheeks, tongue
Undergone surgeries:
	All the information concerning my health condition provided herein is true. I consent to the above information being used for the purpose of treatment.