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Chelsea Dental Studio

Medical-History

Medical and Dental History

Please complete this form by ticking the appropriate boxes and answering the questions;
All details will be strictly confidential.

Do you or have you ever suffered from:
Rheumatic fever?
Any heart complaint (including heart murmur)?
Diabetes?
Epilepsy?
Asthma?
Hay Fever?
Hepatitis?
Jaundice?
Excessive bleeding?
High blood pressure?
Are you allergic to any medicines or materials? (If yes, please give details)
Are you at present taking any medication? (If yes, please give details)
Have you; had any serious illnesses or operations? (If yes, please give details)
Have you; had any previous Orthodontic Treatment? (If yes, please give details below)
Are you or is there a possibility you could be pregnant?
Are you a smoker, if yes how many cigarettes do you smoke per day?
Do you grind or clench your teeth? If yes, we strongly advise you to use a mouthguard.
Do you play any contact sports? If yes, we strongly advise you to use a mouthguard.