Dental Implant Medical History
Full Name
Date of Birth
Age
Sex
Male
Female
Other
Address
Contact Number
Are you currently under a physician’s care?
Yes
No
If yes, please specify the reason
Are you taking any medications?
Yes
No
If yes, please list the medications
Are you allergic to any drugs or substances?
Yes
No
If yes, please specify
Please check if you have or had any of the following:
Heart Disease
Hypertension
Diabetes
Asthma
Bleeding Disorder
Renal Disease
Liver Disease
Thyroid Problems
Epilepsy
Osteoporosis
Other medical conditions
Do you smoke?
Yes
No
If yes, how many per day?
Do you consume alcohol?
Yes
No
For female patients: Are you pregnant?
Yes
No
Additional Remarks / Notes