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MEDICAL HISTORY

    PATIENT DETAILS

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

    MEDICAL HISTORY

    Are you currently:Yes / NoDetails
    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 / NoDetails
    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 / NoDetails
    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 / NoTimes 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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