INTER DENTAL TURKEY
Patient Registration, Medical & Dental History Form
Please complete all relevant fields. For safety questions, tick one answer and give details for every YES or UNSURE response.
Patient / Record No.:
Registration Date:
A. Patient Identification & Communication
B. Visit & Health-Tourism Detailscomplete travel fields only if applicable
C. Critical Safety Alertsfor clinician review after history is completed
Allergy
Anticoagulant / Antiplatelet
Diabetes
Anti-resorptive / Bone Drug
Pregnancy / Possible Pregnancy
Other Urgent Alert
D. Medical HistoryTick YES, NO, or UNSURE / N/A. Give details for every YES or UNSURE response.
Include diagnoses, approximate dates, current status, treating doctor, medication name/dose, and any previous complications where relevant.
| # | Condition / Question | YES | NO | UNSURE / N/A | Details / Medication / Date |
|---|---|---|---|---|---|
| 1 | Medication, food, latex, chlorhexidine or other allergy / serious adverse reaction | ||||
| 2 | Current medicines, injections, over-the-counter drugs, vitamins, supplements or herbal products | ||||
| 3 | Blood thinners / antiplatelet medicines (e.g., warfarin, apixaban, rivaroxaban, aspirin, clopidogrel) | ||||
| 4 | Bleeding disorder, easy bruising, prolonged bleeding or previous transfusion | ||||
| 5 | Heart or circulation disease (heart attack, angina, arrhythmia, heart failure, valve disease, endocarditis, stent, bypass, pacemaker) | ||||
| 6 | High or low blood pressure | ||||
| 7 | Diabetes or blood-sugar disorder | ||||
| 8 | Respiratory condition (asthma, COPD, tuberculosis, significant breathing problem) or sleep apnoea | ||||
| 9 | Kidney disease or dialysis | ||||
| 10 | Liver disease or hepatitis | ||||
| 11 | Thyroid or other endocrine disorder | ||||
| 12 | Epilepsy, seizures, fainting, stroke or other neurological condition | ||||
| 13 | Mental-health condition relevant to treatment, current psychiatric medication, or history of panic during treatment | ||||
| 14 | Immune-system disorder, organ transplant, long-term steroid use or other immunosuppressive treatment | ||||
| 15 | Cancer, chemotherapy, immunotherapy, or radiotherapy - especially head/neck | ||||
| 16 | Osteoporosis / bone disease OR current/past bisphosphonate, denosumab or other anti-resorptive / anti-angiogenic medicine | ||||
| 17 | Pregnant, possibly pregnant, trying to conceive, or breastfeeding | ||||
| 18 | Infectious condition relevant to clinical care (e.g., hepatitis, HIV, active tuberculosis or other significant infection) | ||||
| 19 | Previous surgery, hospital admission, or serious medical procedure | ||||
| 20 | Complication from surgery, sedation, general anaesthesia, local anaesthetic, or any dental treatment | ||||
| 21 | Weight-loss / diabetes injections such as semaglutide or tirzepatide, or other GLP-1/GIP therapy | ||||
| 22 | Smoking, vaping or other nicotine use; alcohol use; recreational / non-prescribed drug use | ||||
| 23 | Any other medical condition, disability or health issue not listed above | ||||
| 24 | Relevant family medical history (e.g., bleeding disorder, serious anaesthetic reaction, heart disease, diabetes, malignant hyperthermia) |
Date:
E. Dental History & Treatment-Relevant Information
Last dental examination / professional cleaning
Date:
History of gum disease / periodontitis or tooth mobility
Dental implants already present
Bruxism / clenching / grinding or night-guard use
Jaw-joint (TMJ) pain, clicking, locking or limited mouth opening
Dry mouth, recurrent mouth ulcers, oral lesions or altered sensation
Previous difficulty becoming numb / reaction to local anaesthetic
Dental anxiety / fear
nonesevere
Main treatment goal / expectation
F. Information Sharing & Privacy Acknowledgement
G. Patient / Guardian Declaration
I confirm that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand that incomplete or incorrect medical information may affect diagnosis, treatment planning, medication choice, healing and patient safety. I agree to tell the clinic about any change in my health, medicines, allergies, pregnancy status or other relevant information before treatment. I understand that this form records my history and does NOT itself authorise a specific dental procedure. Before a procedure requiring consent, the proposed treatment, alternatives, material risks and benefits, important medication information and the consequences of declining treatment will be explained to me, and treatment-specific consent will be obtained separately.
Patient / Legal GuardianName / Signature
Date & Time
Interpreter (if used)Name / Signature / Date
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