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Carlos Alonso

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No one is born hating another person because of the color of their skin or their origin, their sexuality or their religion. If they can learn to hate, they can be taught to love, because love is more natural to the human heart than its opposite. Nelson Mandelas

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Contact information

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Clinic history

Name
Birthdate
Age
Sex
Height
Weight
Home address
Telephone | Cell phone
Main Reason for Consultation
Identification document
Acceptance
I have read the medical history and I am going to respond with complete clarity without omitting any illness that I suffer from.
Reason why I visit the dental office
Has presented complications.
Yeah No
If you have suffered, indicate which
Are you currently being treated by a doctor?
Yeah No
If this is your case, indicate for what disease?
Are you taking any type of medication?
Yeah No
If this is your case, indicate which ones and with what dose?
Are you allergic to a medication?
Yeah No
If this is your case, indicate which ones and with what dose?
Expectations of your treatment in the case of being aesthetic:
Whiter tooth color Bigger teeth Smaller teeth
In the following list of diseases, please mark YES or NO, you have suffered from any. If your answer is affirmative, please describe the treatment received.

Epilepsy or Seizures
Yeah No
Treatment
Anemia
Yeah No
Treatment
Diabetes
Yeah No
Treatment
Hepatitis
Yeah No
Treatment
Hyper or Hypothyroidism
Yeah No
Treatment
Arterial hypertension
Yeah No
Treatment
Angina pectoris
Yeah No
Treatment
myocardial infarction
Yeah No
Treatment
Asthma
Yeah No
Treatment
Tuberculosis
Yeah No
Treatment
Renal insufficiency
Yeah No
Treatment
Venereal diseases
Yeah No
Treatment
HIV/AIDS
Yeah No
Treatment
Gastritis
Yeah No
Treatment
Pregnancy
Yeah No
Treatment
Menopause
Yeah No
Treatment
Cancer
Yeah No
Treatment
Others
Yeah No
Treatment
Extra oral clinical examination

Head
Expensive
ATM
Ganglia
Lips
Particular signs
Observations

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