Right Dental Clinic
Patient Medical History
1
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Address
Phone Number
Email Address
Emergency Contact
2
Dental Concerns
What brings you to the clinic today?
Are you experiencing any pain or discomfort?
Yes
No
Last dental check-up
Previous dental surgery or major procedures?
Yes
No
3
Medical History
Medical Conditions (Check all that apply)
Heart Disease
Blood Pressure
Stroke
Diabetes
Asthma
Liver Disease
Kidney Disease
Bleeding Disorders
Epilepsy
Thyroid Disease
Hiv
Cancer
Other serious illnesses
Have you had any previous surgery (non-dental)?
Yes
No
Currently under a doctor's care?
Yes
No
4
Medications & Allergies
Currently taking any medications?
Yes
No
Taking blood thinners?
Yes
No
Any allergies?
Yes
No
5
Lifestyle
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you use any recreational drugs?
Yes
No
7
X-Ray Upload
Upload X-ray images (up to 20)
Choose files to upload
or drag and drop your files here
PNG, JPG, GIF up to 10MB each
Next Step
