Medical History It is important to know details about your medical history as these could affect the success of your Orthodontic treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our strict privacy policy. Name TitleFirstLast Street Address City Post Code Date of Birth Date Format: YYYY slash MM slash DD SexMaleFemaleName of your DentistOccupation/Name of SchoolYearHealth FundHomeWorkMobileEmail (Required)* Person Paying Account - Name of Person that Referred You - How many brothers/sistersNames and ages of siblingsSibling 1 Name Age Sibling 2 Name Age Sibling 3 Name Age Sibling 4 Name Age Sibling 5 Name Age Have you ever had any of the following, if so, please tick and give any relevant details:Select Heart Trouble or Stroke? Asthma? Rheumatic Fever? Diabetes? High Blood Pressure? Thyroid Trouble? Chest pain? Kidney Trouble? Excessive bleeding? Hepatitis or Liver trouble? Fits or Epilepsy? Stomach or Bowel problems? Do you snore or have sleep apnoea? Skin problems? Do you have any allergies? Especially to metals & latex? Any other medical problems? More InfoHave you been hospitalised in the last 12 months?YesNoHave you had a general anaesthetic or operation of any kind?Are you being treated by a doctor at present?Are you taking any prescription medications at present? Do you smoke? Do you drink alcohol? Have you ever used drugs (intravenous or other)? Are you pregnant or is there a possibility that you may be pregnant?YesNoMaybePregnancy Due Date Date Format: MM slash DD slash YYYY Is there any other relevant information that you may wish to discuss with Dr Mamutil?YesNoRelevant InformationHow did you hear about us?*Referred by DentistReferred by FriendGoogleBrace5 siteInvisalign siteFacebookNewspaper adOther This iframe contains the logic required to handle Ajax powered Gravity Forms.