Confidential Medical History Form

* Required fields

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Are you currently receiving any medical treatment?

Have you had any serious medical problems?

Are you taking any medicines or drugs from your doctor or self prescribed? (tablets, creams, ointments, injections, other). Please list.

Are you taking/ have taken steroids in the last 2 years?

Have you received any radiotherapy?

Are you allergic to any medicine, food or materials? (hayfever, eczema etc.)

Do you suffer from asthma, bronchitis or chest infections?

Have you had jaundice, hepatitis, liver or kidney disease?

Do you have diabetes? If yes, how do you control your diabetes?

Do you have bone or joint problems?

(eg. arthritis)

Have you high or low blood pressure? If yes, do you know what it is?

Have you any other heart problems such as angina, valve problems, heart surgery?

Are you anaemic?

Do you have any blood borne infections?

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Do you bleed a lot if cut, or bruise easily?

Do you have epilepsy, or suffer from fits and faints? 

Have you received treatment for anxiety or depression?

Do you smoke? If so, how many per day?

How many units of alcohol do you have per week? (1 unit= small glass wine,

½ pint beer, 1 measure spirits.)

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Women only

Are you pregnant?

Do you take oral contraceptives?

I consent to my GP being contacted for further medical information if and when required. I consent to photographs and x-rays being taken as required. I understand that these will be used for my clinical records.

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17-18 The Waterfront,

Sovereign Harbour,

Eastbourne,

East Sussex

BN23 5UZ

info@harbour-orthodontics.co.uk

Phone 01323 472100

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