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Medical Questionnaire

Before submitting this form, please ensure that all fields marked with a * are complete.

*
Mobile No:*
*
*
: *

address of your doctor
Post code: *
*
:
*
*
Do you have dental insurance?If so which one?

Are you attending or receiving treatment from a doctor/hospital/specialist? *

Yes No

If yes, please give details:

Are you taking any medicines on a regular basis? (tablets, creams, herbal remedies etc.)*

Yes No

If yes, please give details (if possible please include dosage and frequency):

Have you been hospitalised for a serious illness or operation in the past 3 years?*

Yes No

If yes, please give details:

Are you allergic to any medicines, foods or materials? *

Yes No

If yes, please give details:

Are you or have you been taking steroids in the last two years? *

Yes No

Have you had rheumatic fever or chorea? *

Yes No

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

Yes No

Have you had a heart murmur/attack/problem/angina/blood pressure? *

Yes No

Have you ever been diagnosed with AIDS or HIV? *

Yes No

Do you have any close relatives (parent, sibling, child, grandparent or grandchild) with Creutzfeldt Jakob Disease? *

Yes No

Are you currently pregnant? *           

Yes No

Have you had your blood refused by the Blood Transfusion Service? *

Yes No

Have you had a bad reaction to a general anaesthetic? *

Yes No

Have you had a joint replacement? *

Yes No

Do you carry a warning card? *

Yes No

Do you have arthritis? *

Yes No

Do you have a pacemaker or have you had any form of heart surgery? *

Yes No

Do you take bisphosphonate medication (such as Fosamax or Actonel)? *

Yes No

Did you receive growth hormone treatment before the mid 1980's? *

Yes No

Do you suffer from hayfever, eczema or any other allergy? *

Yes No

Do you suffer from bronchitis, asthma or other chest condition? *

Yes No

Do you have fainting attacks, giddiness, blackouts or epilepsy? *

Yes No

Do you have diabetes or does anyone in your family? *

Yes No

Do you bruise easily or bleed so as to cause concern after surgery? *

Yes No

Do you smoke any tobacco products now (or did you in the past 5 years)? *

Yes No

If yes, how much do (did) you smoke per day?

How many units of alcohol do you drink per week?

Do you have any other aspects concerning your health that we should be aware of? 

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