75/22 Moo:2 Chaofa east road vichit district, 83000 Amphoe Muang Phuket,
Thailand Tel:+6685-182-3244

The dentist Studio

The Dentist Studio
Title Name : *
First Name : *
Last Name :
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Gender Male   Female    *    
Date of birth : /  / 
Country : *  
Phone :  Mobile : *
Email : *
Fax :
       
Address : *
Diabetes or blood sugar iregularities Yes  No 
Cardiovascular/Heart problems Yes  No 
High blood pressure Yes No 
Blood disorders/Blood clotting Yes  No 
HIV or AIDS Yes  No 
If you have answered YES to any of the above, please specify:
Do you have or have you had any other medical conditions not mentioned above? Yes  No 
If yes, please specify:
Have you had any previous dental procedures that you were not satisfied with? Yes  No 
If yes, please specify:
Did you have any complications with this previous dental work? Yes  No 

Do you take birth control pills, hormone replacement medication or wear a hormone patch? Yes  No 
Are you pregnant? Yes  No 
Have you been hospitalised, had surgery or received medical care within the last 12 months?
 Yes  No 
If yes, when and what for?
Do you have any allergies to food, medication, herbs etc.?
 Yes  No 
If yes, when and what for?
Do you smoke? If yes, how many per day?  Yes  No 

Do you drink alcohol? If yes, how many drinks (on average) per day? 
Yes  No 

Do you have or have you had any other medical history that your dentist should be aware of?
 Yes  No 
If YES, please specify:

PHOTOGRAPHS REQUIRED FOR ASSESSMENT
Please provide photos of your teeth. 
 
Please select problematic teeth on the picture and make any remark here. TOP:   
DENTAL CONCERNS
Please select problematic teeth on the picture and make any remark here. BOTTOM:   
If you have multiple problematic teeth, please enter the numbers in the box below as well as any explanation
 
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