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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?

    YesNo

    Taking any prescribed medicines from your doctor?

    YesNo

    Pregnant or possibly pregnant?

    YesNo

    Taking bisphosphonates (medication used for hormone replacement therapy, meopause and osteoporosis)?

    YesNo

    Taking the contraceptive pill or hormone replacement therapy?

    YesNo

    Have you ever had:

    Yes / No

    Details

    Allergies to medicines, foods or materials (e.g. latex / rubber)?

    YesNo

    Rheumatic fever or cholera?

    YesNo

    Jaundice, liver, kidney disease or hepatitis?

    YesNo

    A heart murmur or heart problem, angina, high blood pressure or had a heart attack?

    YesNo

    Any blood tests (other than normal)?

    YesNo

    Your blood refused by a Blood Transfusion Centre?

    YesNo

    A bad reaction to a general or local anaesthetic?

    YesNo

    Brain surgery?

    YesNo

    Growth hormone treatment before the mid 1980s?

    YesNo

    Been hospitalised (in the last five years)? If ‘yes’, what for and when?

    YesNo

    Do you:

    Yes / No

    Details

    Have a close relative with Creutzfeldt Jakob Disease?

    YesNo

    Have arthritis?

    YesNo

    Have a pacemaker, or have had any form of heart surgery?

    YesNo

    Suffer from hay fever, eczema or any other form of allergy?

    YesNo

    Suffer from bronchitis, asthma or other chest condition?

    YesNo

    Have any allergies to any drugs or chemicals?

    YesNo

    Have fainting attacks, giddiness, blackouts or epilepsy?

    YesNo

    Have diabetes, or does anyone in your immediate family?

    YesNo

    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?

    YesNo

    Carry a warning card?

    YesNo

    Ever get cold sores?

    YesNo

    Have any infectious diseases (including HIV or hepatitis)?

    YesNo

    Suffer from any other serious illness?

    YesNo

    Suffer from sleep apnoea?

    YesNo

    Experience jaw joint problems e.g. clicking / pain?

    YesNo

    Are there any other aspects concerning your / your child’s health that you think your orthodontist should know about? (e.g. behavioural difficulties)

    YesNo

    Alcohol and tobacco usage:

    Yes / No

    Times per day

    Do you smoke any tobacco products now or did you in the past?

    YesNo

    Do you chew tobacco, pan gutkha, khat or supari now (or did you in the past)?

    YesNo

    How many units of alcohol do you drink per week?

    FURTHER MEDICAL INFORMATION

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