Medical Chart - Dr Abeer Ammouri Clinic

International Patients

Navigating Your Journey

Patient Medical Chart

Patient Name

Date of Birth

Gender

Male Female

Nationality

Phone

Email

Address

MEDICAL HISTORY

1. Are you currently under the care of a physician?

Yes No

If yes, please provide details:

2. Do you have any known allergies?

Yes No

If yes, please list:

3. Are you taking any medications or supplements?

Yes No

If yes, please list:

4. Have you ever had a reaction to local anesthesia or dental materials?

Yes No

If yes, please provide details:

5. Have you had any surgeries or hospitalizations in the past?

Yes No

If yes, please provide details:

6. Have you ever been diagnosed with any of the following conditions?

Heart disease

Yes No

High blood pressure

Yes No

Diabetes

Yes No

Bleeding disorder

Yes No

Respiratory conditions

Yes No

Contagious diseases like hepatitis B, C, and HIV

Yes No

Other (please specify):

7. Are you pregnant or breastfeeding?

Yes No

DENTAL HISTORY

1. Date of your last dental visit:

2. Reason for your visit to Dr. Abeer Ammouri Clinic:

3. Have you had any previous dental procedures?

Yes No

If yes, please provide details:

4. Do you experience dental anxiety or phobia?

Yes No

If yes, please provide details:

5. Do you smoke or use tobacco products?

Yes No

If yes, please specify:

6. Are you satisfied with the appearance of your teeth and smile?

Yes No

If no, please explain your concerns:

I confirm that the information provided in this medical chart is accurate and complete to the best of my knowledge. I understand that this information will be used to assist in planning and providing appropriate dental or aesthetic treatment at Dr. Abeer Ammouri Clinic.

Date

4th circle, Ibn Khaldoun st.
Building #41
[email protected]

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+962 6 4646669

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INTERNATIONAL PATIENTS

CALL NOW 0775646669

Navigating Your Journey

Patient Medical Chart

+962 6 4646669

Facebook

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dr_abeerammouridentistry

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