Medical History

Name of the family physician

Dr. name

Phone

Date of last visit

Day

Month

Year

Are you suffering from a medical condition, illness or injury?

No

Yes

Have you been hospitalized in the last 12 months?

No

Yes

Do you smoke or Chew tobacco

Yes

No

are you currently taking any prescription medication

Yes

No

If you answered yes to any of the questions above, please supply additional information including name of the medication and purpose.

Have you had any Serious medical problem during past five years?

Yes

No

If yes explain:

Have you been treated for any other illness not listed above?

If yes explain:

are you allergic to any medication?

Any other allergies?

Are you pregnant?

Yes

No

If yes, how many months?

Is there anything else you feel you should tell us about your health that might affect how we care for you? Please explain:

Initials

I declare that the info I’ve provided is accurate and complete.

Dental History

Please fill out the following form.

Reason for your visit today?

How would you describe the condition of your teeth and gums?

Good

Fair

Poor

Are you having discomfort or pain with your teeth? or gums? If yes please explain:

Date of last dental visit? (m/y)

How often do you brush?

Do your gums bleed when you brush?

How often do you floss?

Have you experienced pain in your jaw joint?

Have you been treated for Jaw Pain?

File upload (Image/ Document)

Patient name:

I understand this information to be correct to the best of my knowledge. I understand that it will be held in strict confidence and used only to improve communications between the doctor and myself. I also give permission for the doctor or staff to use any photos or x-rays for educational purposes.

I declare that the info I’ve provided is accurate and complete.

Signature

Signature field is empty.

Patient Forms

Patient Information

Medical History

Dental History

+

DentalTourism

Write to Us

Online Counselling

Find Us @

Tel: +809 248-3000

Padre Boil 14, Gazcue,
Santo Domingo,
Dominican Republic

Tel: +849 506-3000

Arístides Fiallo Cabral 258,
University Zone,
Santo Domingo,
Dominican Republic

Patient Forms

Patient Information

Medical History

Dental History

+

DentalTourism

Write to Us

Online Counselling

Find Us @

Tel: +809 248-3000

Padre Boil 14, Gazcue, Santo Domingo, Dominican Republic

Tel: +849 506-3000

Arístides Fiallo Cabral 258, University Zone, Santo Domingo, Dominican Republic

Padre Boil 14, Gazcue,
Santo Domingo,
Dominican Republic

Arístides Fiallo Cabral 258,
University Zone,
Santo Domingo,
Dominican Republic