Medical Questionnaire

　(Please fill in all relevant information in detail)
  • Full Name (required)
  • NRIC/Passport No.
  • Gender
    male　　　 female
  • Date Of Birth
  • Nationality
  • Occupation
  • Company
  • Contact No. - Home
  • Contact No. - Work
  • Contact No. - Mobile
  • Fax No.
  • Email Address (required)
  • Postal Address
  • Person responsible for fees
  • Whom may we thank for
    referring you?
  • In case of emergency, contact
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  • 1. Are you under medical treatment now?
    • Yes　
    • No
  • 2. Are you taking any medication(s) including non-prescription medicine?
    • Yes　
    • No
  • 3. Do you smoke?
    Yes 　 No
  • 4. Have you been advised to take antibiotics before dental treatment?
    Yes 　 No
  • 5. Do you have any allergies?
    • Yes　
    • No
  • 6. Do you have heart, lung, liver, kidney, blood diseases, Rheumatic
    　fever, High Blood Pressure, Diabetes or any diseases not stated?
    • Yes　
    • No
  • 7. WOMEN ONLY
    • a) Are you pregnant or think you may be pregnant?
      Yes 　 No
    • b) Are you nursing?
      Yes 　 No
    • c) Are you taking oral contraceptives? Antibiotics which are sometimes prescribed for dental infections may decrease the efficacy of oral contraceptives.
      Yes 　 No
  • 8. Reason for your visit today?

Please note that if your health status or medication you take changes during the course of your treatment with us, kindly inform us as it may affect our treatment plan or medications we use.

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I acknowledge that all x-rays, models & photos taken here are part of the practice’s clinical records and therefore remain the property of this clinic. Duplicates of such records can be provided at a fee.


I also understand that any photographs taken of my face, jaws or teeth will be used as a record of my care, and may be used for educational purposes in lectures, demonstrations, advertising and professional publications. However, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.


I certify that I have read and understood the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

I agree with the information & Submit