your question

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Title: ---MrMrsMsOther

Medical Doctor

How did you hear about us: ---GoogleWebsiteWalk byYellow PagesAdvertReferred by your GPPersonal Referral

Do you suffer from any of the following?

High blood pressureHeart ailmentRheumatic feverAsthma, chest or breathing problemsTuberculosisStomach or bowel problems (eg ulcer)Kidney diseaseDiabetesDepression (needing medication)Excessive bleeding or blood disorderEpilepsyHepatitisAIDS/HIVOsteoporosis or bone tumour

Do you smoke: ---NoYes

other previous illness

Would you like to discuss these questions in private with the dentist? ---NoYes

Do you have an artificial hip, heart valve or other prosthetic implant? ---NoYes

Have you ever had problems with dental treatment? ---NoYes

Are you presently under medical care? ---NoYes

Are you taking any drugs, medicines or tablets? ---NoYes

If yes please, list here

Female patients, are you pregnant? ---NoYes

Do you have allergies?
Please list any medicines or products you are allergic to (e.g. Penicillin, Latex ... )

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