international Patient Department Guide Pediatric Dentistry Oral and Maxillofacial Radiology Oral and Maxillofacial Medicine Periodontics Oral and Maxillofacial Surgery Prosthodontics Orthodontics General Dentistry Endodontics Restorative Dentistry Dental Implants International patient admission process The Process Of Receiving Dental Treatments In Faculty Clinic Of School Of Dentistry, Tehran University Of Medical Sciences Registration Form Registration Form Name * Family Name * Name of Father * Sex Male Famle Passport Number Age * تحصیلات دیپلم کارشناسی کارشناسی ارشد دکتری Occupation * E-mail * House Address * تلفن منزل * workplace Address * تلفن محل کار * Mobile Number * chief complaint (CC) * Previous Illness (P.I) * Are you under a doctor’s supervision? Yes No for what reason? Are you taking any medicines? Yes No name of medicine? Does your first-degree family have any specific illness? Yes No Name of the illness if the answer is yes? Heart disease (cardiac) Heart valve replacement Heart attack Endocarditis Rheumatic fever/ Heart Rheumatism History of cardiac surgery Abnormal blood pressure Hematologic disease; anemia, hemophilia Thyroidal disease Hypothyroidism Hyperthyroidism other Thyroidal disease Hepatitis Hepatic disease(jaundice) HIV Gastrointestinal disease History of chemo/radio therapy Tuberculosis Respiratory disease Seasonal allergy asthma Diabetes Renal disease Sinusitis Stroke Epilepsy Seizure Psychological illness Addiction to Cigars Addiction to Alcoho Addiction to Recreational drugs Artificial joints Joint problems Radiology photo (OPG) * Do you have allergy to these following substances? Local anesthetics Aspirin Penicillin Antibiotics Other drugs Food have you ever been hospitalized? Yes NO for what reason? Have you had any surgeries? Yes No for what reason? Have you had blood transfusion? Yes No for what reason? Are you pregnant? No Yes (first trimester) Yes (Second trimester) Yes (Third trimester) History of hepatitis vaccination Yes No Do you have fever, coughing or gastrointestinal problems? Yes No Have you had Corona (COVID 19 disease) recently? Yes No Have you had any contact with patients with Corona? Yes No Did you travel to endemic areas of Corona in last 2 weeks? Yes No What is the result of you PCR test? Positive Negative In case of any other illness, please elaborate: