VALENTINO & GINA

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INFORMATIONS

Ricardo

&

Natalia

August | 24th | 2024
Rustic Pelican | 5pm
2425 N Rocky Point Dr, Tampa, FL 33607

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Informations

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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

Descargar Historía clinica

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YOUR VIRTUAL ADMON

Jeimy Pinto

Valencia Edo. Carabobo

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