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Mr Nigel G Taylor
MDSc, BDS, FDS RCS(Ed), FDTFed 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……….. Gender ………………
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
Ever taken or plan to take YES NO
bisphosphonates
IS THE PATIENT
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.
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