Lovely Dent
Medical Form
Name Surname
Your Phone Number...
E-mail
Adress
Do you have chest pain?
Yes
No
Hypertension?
Yes
No
Shortness of breath?
Yes
No
Asthma / Emphysema?
Yes
No
Coughing up blood?
Yes
No
Reaction to Anesthesia?
Yes
No
Diabetes?
Yes
No
Reflux Disease?
Yes
No
Thyroid Disease?
Yes
No
Arthritis?
Yes
No
Kidney stone?
Yes
No
Blood in urine?
Yes
No
Paralysis?
Yes
No
Neurosis?
Yes
No
Blood transfusion?
Yes
No
HIV?
Yes
No
Hepatitis?
Yes
No
Bleeding Tendency?
Yes
No
Gastric ulcer?
Yes
No
Hernia Surgeries?
Yes
No
Cancer?
Yes
No
Previous Surgeries?
Is there a history of cancer in your family?
Please list all the medications you are currently taking.
Do you have any drug allergies? (Please list them)
Have you ever used Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Is there anything else you'd like to add regarding your health condition?
Approval of the anamnesis form.
I agree
I disagree
Send...