Medical History

Health Status

Medical Health Assessment

Please select YES or NO beside each medical condition.

Heart murmur

Rheumatic fever

High blood pressure

Asthma

Sinus/Hay fever

Gastric problems

Radiotherapy/Chemotherapy

Stroke

Chest & lung disease

Epilepsy

Kidney problems

Smoker

Diabetes

Allergies

Heart attack

Open heart surgery

Pregnant

Artificial/prosthetic joint

Depressive illness

Drugs

List of Medications

Your Details

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I CONFIRM THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

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What Patients Say

For urgent needs call us: 022 340 4887

Dr Siddharath KothariDental Specialist (Prosthodontist)
BDS, GradDipClindent (Advanced Dentistry),
DClinDent (Pros)

Palmerston North

  • 022 340 4887
  • reception@sidkothari.co.nz