Title
Miss
Master
Ms
Mrs
Mr
Name
First Name
Last Name
Address:
Postcode:
Date of Birth:
/
Day
/
Month
Year
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Phone Number
-
Area Code
Phone Number
Mobile:
Email:
example@example.com
Your Doctor's Name & Address:
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Are you?
Attending or receiving treatment from a doctor, hospital, clinic or specialist?
*
Yes
No
Taking any medicines from your doctor (tablets, injections, creams or other)?
*
Yes
No
Taking or have taken any steroids in the last two years?
*
Yes
No
Allergic to any medicines, foods or materials?
*
Yes
No
An expectant mother?
*
Yes
No
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Have you?
Had rheumatic fever or chorea (St Vitus Dance)?
*
Yes
No
Had jaundice, liver, kidney disease or hepatitis?
*
Yes
No
Ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack?
*
Yes
No
Had any blood tests, inoculotions etc?
*
Yes
No
Ever had your blood refused by the Blood Transfusion Service?
*
Yes
No
Had a bad reaction to a general or local anaesthetic?
*
Yes
No
Had a joint replacement?
*
Yes
No
Been hospitalised?
*
Yes
No
What for & when?
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Do you?
Have arthritis?
*
Yes
No
Have a pacemaker or have you had heart surgery?
*
Yes
No
Suffer from asthma, bronchitis or other chest condition?
*
Yes
No
Suffer from hay fever. eczema or other allergy?
*
Yes
No
Have epilepsy, fainting attacks, giddiness or blackouts?
*
Yes
No
Have autism spectrum disorder?
*
Yes
No
Have diabetes or does anyone in your family?
*
Yes
No
Bruise easily or following a tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried?
*
Yes
No
Carry a warning card?
*
Yes
No
Ever get cold sores?
*
Yes
No
Smoke?
*
Yes
No
Drink Alcohol?
*
Yes
No
How many units per week
1 unit = 1 pint beer/ cider | 1 glass wine | 1 shot spirit
If you have answered Yes to any questions or feel that there are any other aspects concerning your health that you think your Orthodontist should know about please provide further details.
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In case of emergency please contact:
Name:
Telephone:
I give consent for discussion of my / my child’s orthodontic treatment to be discussed via e mail/WhatsApp/Zoom or other type of electronic communication
*
Yes
No
Completed by
Name:
Relationship to patient:-
Self
Parent
Guardian
Signature
Clear
Date:
/
Month
/
Day
Year
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