Mr Nigel G Taylor

 

MDSc, BDS, FDS RCS(Ed), FDS RCS(Eng), M’Orth RCS(Ed), D’Orth RCS(Eng)

 

I need to ask patients about their general health so that I can treat them safely. Please write the patient’s details below and then answer the health questions about the patient. All information will be kept confidential.

 

Name of person completing questionnaire, please print ……………………………………………

 

Relationship to patient ……………………Signature ……………………………… Date …………………

 

Patient’s Surname …………………………………….…… Title……….. Male / Female ………………

 

First Names …………………………………… Date of Birth …………………..

 

Address……………………………………………………………………………………………………

 

………………………………………………………………………Postcode ………………………..

 

Tel. Home ……………………………………… Tel. Work…………………………………………..

 

Tel. Mobile …………………………………….. e-mail address ……………………………………

 

School/Occupation ……………………………………………………………………………………….

 

Doctor’s Name & Address ………………………………………………………………………………

 

………………………………………………………………………Tel. …………………………………

 

Dentist’s name & Address ………………………………………………………………………………

 

………………………………………………………………………Tel. …………………………………

 

 

HAS THE PATIENT Please give details below

 

Had rheumatic fever? YES NO

 

Had jaundice e.g hepatitis? YES NO

 

Had any other serious illnesses? YES NO

 

Been admitted to hospital?

(if yes, what for and when?) YES NO

 

Had heart surgery? YES NO

 

Had a bad reaction to a

local anaesthetic? YES NO

 

Had a bad reaction to a

general anaesthetic? YES NO

 

Bled excessively following an

injury, surgery or a tooth extraction

(or has anyone in the family)? YES NO

 

Had blood refused by the Blood

Transfusion Service? YES NO

Please turn over

 

IS THE PATIENT Please give details below

 

Receiving treatment from a

doctor, hospital or clinic? YES NO

 

Taking steroids (now or in

the last 2 years)? YES NO

 

Taking any other medicines or

drugs e.g. tablets, HRT, contraceptives,

creams, injections or inhalers? YES NO

 

Allergic to any medicines

foods or materials e.g. latex? YES NO

 

Pregnant or possibly pregnant YES NO

 

DOES THE PATIENT

 

Smoke any tobacco products YES NO IN PAST …………..……..times a day?

 

Chew tobacco, pan, use gutkha or supari YES NO IN PAST ………...………..times a day?

now or in the past

 

Drink alcohol YES NO IN PAST …….………...units per week?

 

Have any heart problems, angina

blood pressure, or stroke? YES NO

 

Have any chest problems

e.g. asthma or bronchitis? YES NO

 

Have fits, fainting attacks

giddiness, or blackouts? YES NO

 

Have diabetes? YES NO

  a bleeding disorder? YES NO

kidney disease? YES NO

liver disease? YES NO

bone or joint disease? YES NO

 

Carry a medical warning card,

bracelet or warning token? YES NO

 

DENTAL QUESTIONS

 

Has the patient worn a brace before? YES NO

 

If yes, what kind of brace was this? ……………………………………………………………….

 

If yes, who provided the treatment? ……………………………………………………………….

 

Has the patient ever injured his/her teeth? YES NO

 

If yes, please describe the injury ………………………………………..……………………..…..

 

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

 

Please make sure that any changes to the patient’s medical history are reported to me straightaway.

To comply with the 1998 Data Protection Act may I confirm that personal data is recorded and processed in order to provide orthodontic care. This information remains confidential.