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Phone no:
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Patient Medical History
Home
About Us
Patient info
Our Services
Team
Contact us
Forms
Referral
Patient Medical History
Patient Medical History
Name:
Dr
Mr
Mrs
Miss
Ms
Your Address (required)
Date of Birth
Home phone
Work phone
Mobile
Email address
Emergency contact
Occupation
Health Fund Provider
Who is your Medical GP?
Please list all current medications you are taking
What concerns do you have with your dental conditions? (eg loose teeth, breath, missing teeth)
MEDICAL HISTORY: Please answer the following
Any known Allergies:
Yes
No
Details:
High/Low Blood Pressure:
Yes
No
Details:
Do you suffer from Excessive Bleeding? :
Yes
No
Details:
Have you had Radiotherapy/Chemotherapy? :
Yes
No
Details:
Do you have: Heart condition/Heart valve disorder/Murmur? :
Yes
No
Details:
Have you had Hepatitis A/B/C :
Yes
No
Details:
Do you suffer from Respiratory conditions? :
Yes
No
Details:
Have you had Rheumatic fever? :
Yes
No
Do you have Epilepsy?:
Yes
No
Details:
Do you have Diabetes? :
Yes
No
Details:
Do you have Asthma? :
Yes
No
Details:
Do you have Tuberculosis? :
Yes
No
Details:
Do you have a Stomach or Digestive condition? :
Yes
No
Details:
Do you have a Prosthetic Implant? (hip, knee, shoulder) :
Yes
No
Details:
Do you have Bronchitis, Emphysema or other lung disease? :
Yes
No
Details:
Do you have Anaemia, Leukaemia or other blood disorders? :
Yes
No
Details:
Have you had a Stroke? :
Yes
No
Details:
Have you had a Kidney Disease?:
Yes
No
Details:
Do you Smoke or have you smoked in the past? :
Yes
No
Details:
Do you need Antibiotics before dental treatment? :
Yes
No
Details:
Have you had an Organ or Marrow Transplant? :
Yes
No
Details:
Women, are you pregnant?:
Yes
No
Details:
Women, are you breastfeeding?:
Yes
No
Details:
Exposure to HIV or other liver disease? :
Yes
No
Details:
Do you have Osteoporosis? :
Yes
No
Details:
Do you have Thyroid Disease? :
Yes
No
Details:
Do you have a Cardiac Pacemaker? :
Yes
No
Details:
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