Health & medical requirements

Medical history form

Review Dental Nation's patient registration and medical history form below. Download or print a copy to complete before your visit, or bring the details with you to reception.

Download form

Submit personal and health information only through Dental Nation's approved secure process. The version below is for reference and printing.

Patient Information

Last NameFirst Name

GenderMale Female

Marital StatusMarried Single Child

Date of Birth (Day / Month / Year)NationalityP.O. BoxCityAddressEmailPhoneMobile

Residency StatusResident UAE National Tourist

Proof of IdentityPassport Emirates ID

Company NameInsurance ProviderHow did you hear about us?

Medical History

Are you in good health?Yes No

Have you had any of the following conditions?

Heart or heart valve issuesYes No

High blood pressureYes No

Hemophilia or prolonged bleedingYes No

AsthmaYes No

DiabetesYes No

EpilepsyYes No

Hepatitis or HIVYes No

Liver or kidney issuesYes No

Thyroid issuesYes No

Serious illnesses or surgeryYes No

Dental History

Have you had serious dental issues?Yes No

Have you ever been treated for gum disease?Yes No

Are you happy with your smile?Yes No

Date of your last dental visit

Do you have or have you ever had problems with:

Bleeding gumsYes No

Bad taste or bad breathYes No

Frequent ulcers (lips/mouth)Yes No

Swelling or lumps in the mouthYes No

BracesYes No

Biting cheeks/lipsYes No

Clicking or popping jawYes No

Difficulty opening/closing the jawYes No

Loose teethYes No

Sensitivity to hot or coldYes No

Sensitivity to sweetsYes No

Sensitivity to bitingYes No

Food getting stuckYes No

Clenching or grinding teethYes No

Coffee or tea consumptionYes No

Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge. I understand that my records will be kept confidential.

NameSignatureDate