Thank you for visiting Surgical Services International Dental Consultation Form. We will forward your medical details to your surgeon who will reply with his/her clinical evaluation and any questions he may have for you.
Have you seen a dental implant specialist or dentist? Have they determined that you are good candidate for implants and that you have enough bone density? Please describe: |
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Do you currently have any problems in the following areas? |
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Yes |
No |
If yes, please explain: |
General / Constitutional
(fever, weight loss, other) |
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Ears, Nose, and Throat
(cold, sinus, chronic cough) |
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Cardiovascular
(heart, vessels, etc.)
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Respiratory
(asthma, emphysema, etc.) |
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Gastrointestinal
(ulcers, intestinal disease, etc.) |
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Genital, Kidney, Bladder |
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Skin
(rosacea, skin cancer, psoriasis, etc.) |
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Neurological
(MS, stroke, seizures, etc.) |
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Psychiatric
(anxiety, depression, etc.) |
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Endocrine
(diabetes, thyroid, etc.) |
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Blood / Lymph
(bleeding disorder, high cholesterol, anemia, etc.) |
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Allergic / Immunologic
(lupus, hay fever, rheumatoid arthritis, etc.) |
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