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Patient Survey

Medical History

    PATIENT DETAILS

    PARENT / GUARDIAN DETAILS (necessary for patients under 18 years)

    MEDICAL HISTORY

    Are you currently: Yes / No Details
    Receiving treatment from a doctor, hospital clinic or specialist?
    Taking any prescribed medicines from your doctor?
    Pregnant or possibly pregnant?
    Taking bisphosphonates (medication used for hormone replacement therapy, meopause and osteoporosis)?
    Taking the contraceptive pill or hormone replacement therapy?
    Have you ever had: Yes / No Details
    Allergies to medicines, foods or materials (e.g. latex / rubber)?
    Rheumatic fever or cholera?
    Jaundice, liver, kidney disease or hepatitis?
    A heart murmur or heart problem, angina, high blood pressure or had a heart attack?
    Any blood tests (other than normal)?
    Your blood refused by a Blood Transfusion Centre?
    A bad reaction to a general or local anaesthetic?
    Bone or joint disease, or joint replacement?
    Brain surgery?
    Growth hormone treatment before the mid 1980s?
    Been hospitalised (in the last five years)? If ‘yes’, what for and when?
    Do you: Yes / No Details
    Have a close relative with Creutzfeldt Jakob Disease?
    Have arthritis?
    Have a pacemaker, or have had any form of heart surgery?
    Suffer from hay fever, eczema or any other form of allergy?
    Suffer from bronchitis, asthma or other chest condition?
    Have any allergies to any drugs or chemicals?
    Have fainting attacks, giddiness, blackouts or epilepsy?
    Have diabetes, or does anyone in your immediate family?
    Bruise easily, or following a tooth extraction or surgery have you or a family member bled heavily so as to cause you to be worried?
    Carry a warning card?
    Ever get cold sores?
    Have any infectious diseases (including HIV or hepatitis)?
    Suffer from any other serious illness?
    Suffer from sleep apnoea?
    Experience jaw joint problems e.g. clicking / pain?
    Are there any other aspects concerning your / your child’s health that you think your orthodontist should know about? (e.g. behavioural difficulties)
    Alcohol and tobacco usage: Yes / No Times per day
    Do you smoke any tobacco products now or did you in the past?
    Do you chew tobacco, pan gutkha, khat or supari now (or did you in the past)?

    FURTHER MEDICAL INFORMATION

    TEXT/EMAIL REMINDERS


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