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Patient Medical History













    MEDICAL HISTORY: Please answer the following

    Any known Allergies: YesNo

    Details:

    High/Low Blood Pressure: YesNo

    Details:

    Do you suffer from Excessive Bleeding? :YesNo

    Details:

    Have you had Radiotherapy/Chemotherapy? : YesNo

    Details:

    Do you have: Heart condition/Heart valve disorder/Murmur? :YesNo

    Details:

    Have you had Hepatitis A/B/C : YesNo

    Details:

    Do you suffer from Respiratory conditions? : YesNo

    Details:

    Have you had Rheumatic fever? : YesNo

    Do you have Epilepsy?: YesNo

    Details:

    Do you have Diabetes? : YesNo

    Details:

    Do you have Asthma? : YesNo

    Details:

    Do you have Tuberculosis? : YesNo

    Details:

    Do you have a Stomach or Digestive condition? : YesNo

    Details:

    Do you have a Prosthetic Implant? (hip, knee, shoulder) :YesNo

    Details:

    Do you have Bronchitis, Emphysema or other lung disease? : YesNo

    Details:

    Do you have Anaemia, Leukaemia or other blood disorders? :YesNo

    Details:

    Have you had a Stroke? : YesNo

    Details:

    Have you had a Kidney Disease?: YesNo

    Details:

    Do you Smoke or have you smoked in the past? : YesNo

    Details:

    Do you need Antibiotics before dental treatment? :YesNo

    Details:

    Have you had an Organ or Marrow Transplant? : YesNo

    Details:

    Women, are you pregnant?: YesNo

    Details:

    Women, are you breastfeeding?: YesNo

    Details:

    Exposure to HIV or other liver disease? :YesNo

    Details:

    Do you have Osteoporosis? : YesNo

    Details:

    Do you have Thyroid Disease? : YesNo

    Details:

    Do you have a Cardiac Pacemaker? : YesNo

    Details:

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