For dentist
English
O'zbekcha
Русский
English
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Name
*
Surname
*
Sex
*
Man
Woman
Birth date
Phone number
*
+998
E-mail
Address
*
Password
*
Confirm password
*
Illnesses
Diabet
*
No
Yes
Not checked
How many times anesthesed?
*
Not anesthesed
1 marta
2 marta
3 and more
Hepatitis (B or C)
*
No
Yes
Not checked
AIDS
*
No
Yes
Not checked
Blood pressure
*
Normal
Low
High
Allergy
*
No
Yes (enter what you are allergic to)
Bronchial asthma
*
No
Yes
Dizziness
*
No
Sometimes
Often
Fainting
*
No
Sometimes
Often
Other illnesses
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Epilepsy
No
Yes
Medications
No
Yes (which)
Have you had a stroke?
No
Yes
Have you had a heart attack?
No
Yes
Oncologic illnesses
No
Yes
Tuberculosis
No
Yes
Do you drink alcohol?
No
Sometimes
Often
Pregnancy
No
Yes (which month)
Do you breastfeed?
No
Yes
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