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………..                                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

 

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.