19/25 Moo 6 Vichitsongkram Road, Kathu District, Phuket, 83120 Tel:081-7878038

Phuketdentalstudio

Phuket Dental Studio

PERSONAL INFORMATION

MEDICAL CONDITIONS (are you suffering from any of the following conditions, please indicate YES or NO)

WOMEN

Do you take birth control pills, hormone replacement medication or wear a hormone patch?	Yes	No
Are you pregnant?	Yes	No

MEDICAL HISTORY

STEP 2: DENTAL CONCERNS

PHOTOGRAPHS REQUIRED FOR ASSESSMENT
Please provide photos of your teeth.

Please select problematic teeth on the picture and make any remark here.

TOP:

Please select problematic teeth on the picture and make any remark here.

BOTTOM:

If you have multiple problematic teeth, please enter the numbers in the box below as well as any explanation

Type the code shown :

Diabetes or blood sugar iregularities	Yes	No
Cardiovascular/Heart problems	Yes	No
High blood pressure	Yes	No
Blood disorders/Blood clotting	Yes	No
HIV or AIDS	Yes	No
If you have answered YES to any of the above, please specify:
Do you have or have you had any other medical conditions not mentioned above?	Yes	No
If yes, please specify:
Have you had any previous dental procedures that you were not satisfied with?	Yes	No
If yes, please specify:
Did you have any complications with this previous dental work?	Yes	No

Have you been hospitalised, had surgery or received medical care within the last 12 months?	Yes	No
If yes, when and what for?

Do you have any allergies to food, medication, herbs etc.?	Yes	No
If yes, when and what for?

Do you drink alcohol? If yes, how many drinks (on average) per day?	Yes	No

Do you have or have you had any other medical history that your dentist should be aware of?	Yes	No
If YES, please specify: