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Patient Information
Male Female
Married Single Child
Day ____ Month ____ Year ______
Resident UAE National Tourist
Passport Emirates ID
Medical History
| Are you in good health? | Yes No |
Have you had any of the following conditions?
| Heart or heart valve issues | Yes No |
| High blood pressure | Yes No |
| Hemophilia or prolonged bleeding | Yes No |
| Asthma | Yes No |
| Diabetes | Yes No |
| Epilepsy | Yes No |
| Hepatitis or HIV | Yes No |
| Liver or kidney issues | Yes No |
| Thyroid issues | Yes No |
| Serious illnesses or surgery | Yes No |
| Other medical problems | Yes No |
| Do you have allergies? | Yes No |
| If yes, please specify | |
| Are you taking any medications? | Yes No |
| If yes, please specify | |
| Do you smoke? | Yes No |
| Are you pregnant? | Yes No |
| Are you experiencing any discomfort? | Yes 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 gums | Yes No |
| Bad taste or bad breath | Yes No |
| Frequent ulcers (lips/mouth) | Yes No |
| Swelling or lumps in the mouth | Yes No |
| Braces | Yes No |
| Biting cheeks/lips | Yes No |
| Clicking or popping jaw | Yes No |
| Difficulty opening/closing the jaw | Yes No |
| Loose teeth | Yes No |
| Sensitivity to hot or cold | Yes No |
| Sensitivity to sweets | Yes No |
| Sensitivity to biting | Yes No |
| Food getting stuck | Yes No |
| Clenching or grinding teeth | Yes No |
| Coffee or tea consumption | Yes 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.