Medical Questionnaire - Grunhaus Dental

Complete the following form

1. Personal Information
*Name:**					Middle name:
*Last name:**					Gender:		Male Female
Date of birth:	Month		Day	Year	Age:
Address:
Occupation:					Phone:
*E-mail:**					Fax:
2. Please check the procedures you are interested in:
Dental Implants		Number of implants:
Periodontal Treatments		Cosmetic "gum" surgery				Scalling root planning
		Periodontal surgical procedures				Prophylaxis (Cleanings)
Dental Procedures		Tooth whitening				Veneers
		Fixed partial dentures (Crown and bridges)				Root canals therapy
		Dental fillings (Amalgams and composites)				Dentures
3. Medical History
Please answer the following questions:
1-You ever suffered one or some of the following illnesses?
Heart diseases		High blood pressure				Kidney
Diabetes		Epilepsy				Coagulation disorders
Psychiatric diseases		Alcoholism				Ulcer/gastritis
Asthma
2-How is your general health?
3-Are you taking any kind of medication?						No Yes
						List them
4-Have you ever have any negative experience with local anesthetics?						No Yes
						Please specify
5-Are you allergic?						No Yes
						List them
6-Do you take aspirins or products that contains it?						No Yes
						Which ones?
7-Do you use tobacco?						Daily Occasionally No
8-Do you drink alcohol?						Daily Occasionally No
9-Have you ever had any other surgery before?						No Yes
						Please name them and write down the dates:

10-If you have any other medical information of importance, please specify:

Clínica
Grunhaus

Phone Number (506) 2257-9145
(506) 2257-8632

For more information about Clínica Grunhaus, please fill out our Request Information Form or email us to: info@igzdental.com