The Smile Team Medical & Social History Questionnaire
Patient's name
First Name
Last Name
Heart complaint, heart surgery or stroke?
Yes
No
Please provide details:-
Rheumatic fever?
Yes
No
Please provide details:-
High blood pressure?
Yes
No
Please provide details:-
Excessive bleeding?
Yes
No
Please provide details:-
Diabetes?
Yes
No
Please provide details:-
Chronic bronchitis or asthma
Yes
No
Please provide details:-
Epilepsy or fainting attacks?
Yes
No
Please provide details:-
Hepatitis?
Yes
No
Please provide details:-
Cancer?
Yes
No
Please provide details:-
Any other illness?
Yes
No
Please provide details:-
In the past two years have you undergone any operation?
Yes
No
Please provide details:-
Have you ever had a joint replacement?
Yes
No
Please provide details:-
HIV positive?
Yes
No
Please provide details:-
What is your average weekly alcohol consumption?
Do you smoke?
Yes
No
How many a day?
Are you: Allergic to any tablets, or latex?
Yes
No
Please provide details:-
At present are you taking any medication or tablets?
Yes
No
Please list the names of medication or tablets:-
Doctors name and address:
Patients/Parents/Guardian signature
Please use mouse, or finger, to draw your signature here
Date
/
Day
/
Month
Year
Date
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