The London Orthodontic Group

Medical Questionnaire

It is important for your clinician to have your medical history and understand your health needs before any examination or treatment is carried out.

Please kindly complete this medical questionnaire as fully and accurately as possible. Your answers will be treated in the strictest confidence in accordance with the Data Protection Act

Patient Form

If you are human, leave this field blank.

Please choose which practice is this appointment booked for.

Practice *

Knightsbridge

Richmond

Teddington

Patient Information

Title *

First Name *

Surname *

Date of Birth *

Occupation *

Ethnicity *

Address *

Address

City

County

Post Code

Home Telephone *

Mobile *

Child's Mobile

Email Address *

NHS Number (If Under 18)

Your Dentist’s Name *

Dentist’s Phone Number *

Dental practice Name *

GP practice Name *

GP’s name *

GP’s number *

How did you hear about us? *

How did you hear about us (Details)?

Parent/Guardian (if applicable):

(Mother) Title

First Name

Surname

(Father) Title

First Name

Surname

Confidential medical history form

To obtain the best and safest treatment, we would like to know of any problems which may affect your treatment

Are you:

Attending or receiving treatment from a doctor/ hospital/specialist? *

Details Attending or receiving treatment from a doctor/ hospital/specialist?

Taking any medicines from your doctor? (tablets/injections/other) *

Details for Taking any medicines from your doctor? (tablets/injections/other)

Allergic to any medicines/foods or materials? *

Details for Allergic to any medicines/foods or materials?

Have you ever had

Rheumatic fever? *

Details for Rheumatic fever?

Hepatitis/jaundice/liver or kidney diseases? *

Details for epatitis/jaundice/liver or kidney diseases?

Any problems with your heart? *

Details for Any problems with your heart?

Do you have any of the following:

Arthritis *

Details for Arthritis

Asthma or other chest/breathing problems? *

Details for Asthma or other chest/breathing problems?

Fainting attacks/giddiness/blackouts or epilepsy? *

Details for Fainting attacks/giddiness/blackouts or epilepsy?

Diabetes? *

Details for Diabetes?

Bruising or bleeding problems? *

Details for Bruising or bleeding problems?

A warning/medical alert card? *

Details for A warning/medical alert card?

Do you

Have a learning disability? *

Details for Have a learning disability?

Smoke any form of tobacco/ use e-cigarettes? *

How many per day?

When did you stop?

Drink alcohol *

How many units per week?
1 pint of lager or a medium glass of wine= 2 units

Are there any other aspects concerning your health that you think we should know about?

Completed By *

Patient

Parent/Guardian

Date *
Checked by the Orthodontist:

Section

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Our practice follows agreed procedures to keep your information secure and private. Your personal information will never be passed to third parties unless we are making a professional referral for you. For more information, please see our Privacy Notice published on our website www.LondonLovesBraces.com/privacynotice.