Are you receiving treatment from a doctor, hospital or clinic? YesNo
Are you taking any prescribed medicines? YesNo
Do you carry a medical warning card? YesNo
Are pregnant/expecting a baby? YesNo
Do you have any allergies to any medicines, substances or food? YesNo
Do you have bronchitis, asthma or other chest condition? YesNo
Have you ever had any fainting attacks, giddiness, blackouts or suffer from epilepsy? YesNo
Do you have diabetes (or does anybody in your family)? YesNo
Do you have any bone of joint disease? YesNo
Have you ever had any bruising or persistent bleeding following injury, tooth extraction or surgery? YesNo
Do you have liver or kidney disease? YesNo
Do you have any other serious illness or infectious disease? YesNo
Have you ever had blood refused by the Blood Transfusion Service? YesNo
Have you ever needed any treatment that required a hospital stay? YesNo
Have you ever had heart surgery? YesNo

How many units of alcohol do you drink per week?
Do you smoke tobacco products now (or in the past)? YesNoIn the past
Do you chew tobacco, pan, use gutkha or supan now (or in the past)? YesNoIn the past

Has the patient worn a brace before? YesNo
Has the patient ever injured his/her teeth or face? YesNo

Is there anything else about the patient’s health or activities that you think the orthodontist should know about?

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Are you receiving treatment from a doctor, hospital or clinic? YesNo
Are you taking any prescribed medicines? YesNo
Do you carry a medical warning card? YesNo
Are pregnant/expecting a baby? YesNo
Do you have any allergies to any medicines, substances or food? YesNo
Do you have bronchitis, asthma or other chest condition? YesNo
Have you ever had any fainting attacks, giddiness, blackouts or suffer from epilepsy? YesNo
Do you have diabetes (or does anybody in your family)? YesNo
Do you have any bone of joint disease? YesNo
Have you ever had any bruising or persistent bleeding following injury, tooth extraction or surgery? YesNo
Do you have liver or kidney disease? YesNo
Do you have any other serious illness or infectious disease? YesNo
Have you ever had blood refused by the Blood Transfusion Service? YesNo
Have you ever needed any treatment that required a hospital stay? YesNo
Have you ever had heart surgery? YesNo

How many units of alcohol do you drink per week?
Do you smoke tobacco products now (or in the past)? YesNoIn the past
Do you chew tobacco, pan, use gutkha or supan now (or in the past)? YesNoIn the past

Has the patient worn a brace before? YesNo
Has the patient ever injured his/her teeth or face? YesNo

Is there anything else about the patient’s health or activities that you think the orthodontist should know about?

submit