Medical History Form

Full Name *

First NameLast Name

Your address *

What is your gender? *

Date of birth *

Date

Contact Number *

Area CodePhone Number

Email Address *

example@example.com

In event of an emergency,please contact relative/GP: *

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: *

Check the symptoms that you' re currently experiencing: *

Are you currently taking any medication? *

YesNo

Please list them.

Do you have any medication allergies? *

YesNoNot Sure

Please list them.

Do you use any kind of tobacco or have you ever used them? *

How many cigg a day? How long have you used/been using them?

Do you consume alcohol? *

How many units alcohol a day

Signature *

SIGN IN THE LOWER HALF

Date *

Date