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First Name / Last name: ………………………………………… Birth Date: …………………………………………………
Address: ………………………………………………………………………………………………………………………….
Tel.(home): ……………………. Tel.(mobile): …………………… Tel.(at work): ………………………………………….
Identity Card: ………………………………………………………………………………………………………………….
Contact Person (if you aren’t available):……………………………………. Tel: …………………………………….….….
How did you find Our Clinic? ………………………………………………………………………………………………….
Patient’s Medical Chart
(Mark the correct answer where is the case)
The date of the last medical consult (Medical Investigations) ………………………………………………………………….
1) Have you suffered any major medical intervention in your past? ………………………………………………… ……….
…………………………………………………………………………………………………………………………………….
2) Are you currently following any kind of treatment? ……………………………………………………………………….
3) Are you allergic or have adverse reactions to:
infiltration anesthesia
-Hepatitis.………………………….………… -Thyroid gland Disease…………….…………………………….
- HIV Infection. ……………………………. - Immune System Disease……………………………………….
-Diabetic.……….…………….…….………. - Blood Coagulate Disorder (hemophilia). ………………….…….
-Venereal Disease….….……………………… - Unusual Bleedings …………………………………………….
-Ulcer………………………………………… - Spasmophilia …………………………………………………….
-Renal Disease………………………….……. - Epilepsy ……………………………………………….……….
-Tuberculosis………………………………… - Hypocalcaemia. …………………………………………………
Special Notes:
In case that you have any major health problems, please tell us about:

Authorization
I have read and understood this form and that I have answered correctly and truthfully to questions above, and my answers
reflect the real state of my health. I understand that hiding information can put my health into danger, and I will not hold
responsible the clinic’s staff for any omission that I may have made.
Patient’s signature or one of the parent’s signature if the patient is under age. X………………………………………………
Doctor’s comments_______________________________________________________________________________
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Clinical Investigations:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Arterial pressure:

Source: http://www.netproiect.ro/opran/Opran%20Dental%20Clinic%20-%20Patient's%20Chart.pdf