TDH Pre-Assessment Dental Form

General information

Name

First

Last

Contact number

Email

Age

Gender

Nationality

Desired Treatment

Dental you Last

Please Specify: Chief Complaint / Dental Concern / Symptoms / Teeth Position

Time symptoms first occur(onset)

Last dental visit

Medical history

Chronic disease (if any)

Yes
No

Please Specify

Current medications (if any)

Yes
No

Please Specify

Drug allergies (if any)

Yes
No

Please Specify

Food allergies

Yes
No

Please Specify

Surgical operation History (if any)

Yes
No

Please Specify

Organ Transplant (if any)

Yes
No

Please Specify

Do you drink alcohol?

Yes
No
Occasionally

Are you a smoker?

Yes
No

Do you currently have any existing dental fixtures, appliance?

Yes
No

Please specify brand / type / tooth position

Treatment by:

By TDH Dental
From other dental practice

Travel history

Do you reside in Thailand?

Yes
No (If not, please specify country of residence)

country of residence

Do you have plans to travel abroad or travel by plane during this time?

Yes (If yes, please provide approximate travel date)
No

(If yes, please provide approximate travel date)

Attach file

Click or drag a file to this area to upload.

It will be helpful to get x-rays and/or any documentation of the previous dental work/s.

*This information will help our dental team prepare as best as possible for your safety.