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Thank you to have booked a virtual consultation with me. Please follow the next instruction in order to set up everythings ready for our call. Please compile the form and upload the file I need to check.

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Please take 10 minutes to answer some questions.

First Name

Last Name

Patient Age

Patient Gender

Phone no.

Marital Status

Married

Unmarried

other

Marital status(other)

Occupation

Disability ?

Yes

No

General Medical History

Are you in good general health?

Yes

No

Are you PRESENTLY under a physician's care?

Yes

No

If Yes, please include your Physicians Information

Has there been any change in your general health in the past year?

Yes

No

My last physical examination was on:

Have you had any serious illness or operation?

Yes

No

If Yes, please list:

Cardiovascular System

Do you have or have ever had any of the following: Please check

Heart trouble

Heart attack

Coronary insufficiency

Mitral valve prolapse

Stroke

Damaged heart valves

Congenital heart disease

Rheumatic heart disease, heart murmur?

Yes

No

Chest pain after exertion?

Yes

No

Shortness of breath after mild exercise

Yes

No

Do you have ankles swell?

Yes

No

Do you use extra pillow to sleep?

Yes

No

Do you have a cardiac pacemaker?

Yes

No

Do you have any blood pressure problem? if YES:

High

Low

Central Nervous System

Do you have or have you ever had:

Epilepsy

Fainting Spells

Seizures

Emotional disturbances

Do you follow any treatment for a nervous disease?

Yes

No

Respiratory System

Do you have a persistene cough or cold?

Yes

No

Do you have or have you ever had tuberculosis?

Yes

No

Do you have any sinusitis, sinus trouble?

Yes

No

Do you have emphysema, chronic bronchitis, asthma?

Yes

No

Digestive System

Do you have any stomach ulcers?

Yes

No

Do you have or have you ever had?

Acid Reflux (GERD)

Hepatitis

Jaundice

Liver Disease

Have you ever vomitted blood?

Yes

No

Do you have ANY diarrhea?

Yes

No

Endocrine System

Do you have diabetes?

Yes (Controlled)

Yes (Uncontrolled)

No

Does anyone in your family have diabetes?

Yes

No

Do you urinate more than six times a day?

Yes

No

Are you thirsty very often or have dry mounth?

Yes

No

Do you have hypothyroidism or hyperthyroidism?

Yes

No

Hematogenic System

Do you have anemia, Sickle cell disease or any other blood disorder?

Yes

No

Is there ANY family history of blood disorders?

Yes

No

Are you hemophilic?

Yes

No

Have you ever had abnormal bleeding after any surgery, extration or trauma?

Yes

No

Have you ever had a blood transfusion?

Yes

No

Immunodeficiency problem?

Yes

No

Allergies

Are you allergic or have you reacted adversely to:

Local anesthetic

Penicillin

Barbiurates, sedatives, or sleeping pills

Iodine

Latex

Hay fever

Hives or skin rash

Antibiotics

Sulfa Drugs

Aspirin

Codeine or other narcotics

Asthma

Seasonal allergies

Genitourinary System

Do you have or have you ever had?

Kidney trouble

Dialysis

Syphillis, gonorrhea

Bones & Joints

Do you have or have ever had?

Arthritis

Inflammatory rheumatism

Bone infection

Bone infection

Osteporosis

Artificial Join Replacement

Receive or currently receiving the intravenous medication known as Zomata (IV) or Aridia (IM)

Currently taking or have taken the oral medication bisphosphate for osteoporosis or Fosamax, Acetonal or Boniva

Have you noticed any changes in your mounth or jaws?

Yes

No

Have you notices any foul smell, swelling or discharge in your mounth?

Yes

No

Other

Do you have or have you ever had?

Tumor or malignancy

Chemiotherapy or radiation therapy

Do you have or have you ever had ANY Disease or condition or problem NOT listed above that you think we should know about? If so, please explain:

Are you regularly exposed to x-rays or ANY other ionizing radiation or toxic substances?

Yes

No

Do you have glaucoma? if so:

Yes (Wide)

Yes (Close)

no

Are you wearing or do you wear contact lenses?

Yes

No

Do you do any of the following:

Smoke tobacco

Drink alcohol

Use oral tobacco

For women

Are you currently:

Pregnant

Undergoing hormonal therapy

Taking oral contraceptives

Nursing

Do you have any problems associated with your menstrual cycle?

Yes

No

Your Medication

Medication List, please wirte what kind of medication you are taking as well as the dosage (Prescription or over the Counter)

Dental history

What is your cheif dental complaint?

Are you experiencing any discomfort or pain at this time?

Yes

No

Are you satisfied with the appearance of your teeth?

Yes

No

Are you able to eat or chew foods satisfactorily?

Yes

No

Do you have headaches, earaches, or neck pain?

Yes

No

Do you frequently experience sinus problems?

Yes

No

Have you ever had ANY serious trouble associated with ANY previous dental tratment? If yes, please explain:

Allergies

Artificial Joints

Bisphosphate Fosimax

Carpal Tunnel Syn

Dizziness

Fainting

Hay Fever

Heart Murmur

HIV

Jaundice

Liver Disease

Nervours Disorders

Pacemaker

Pre Medicate

Respitory Problems

Sinus Problems

Sulfa Allergy

Tubercolosis

Venereal Disease

Checkbox Field

Anemia

Aspirin Allergy

Blood Disease

Codeine Allergy

Epilepsy

Glaucoma

Head Injuries

Hepatitis

Hyperthyroidism

Kidney Disease

Mental Disorder

Osteoporosis

Penicillin Allergy

Pregnany

Rheumatic Fever

Stomach Problems

Swollen Glands, Neck

Tumors

Zythromax Allergy

Checkbox Field

Arthritis

Asthma

Cancer

Diabetes

Excessive Bleeding

Growths

Heart Disease

High Blood Pressure

Hypothyroidism

Latex Allergy

MVP

Other

Percocet Allergy

Radiation Treatment

Theumatism

Stroke

Topical Anesthetic

Ulcers

Upload medical records

Upload your blood exam no older than 6 months

Choose File

Upload your last x-ray no older than 1 year

Choose File

Take a photo of your teeth with your cell. Upper maxilla and lower. You need to introduce the movil for both archs. then you take one with open mouth. The last one is with close mouth.

Choose File

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