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Torque Orthodontics / Patient info / New patient forms / New Patient - Child form

Personal medical information

Kindly fill in form for your Medical history or download our form below.

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PERSONAL & MEDICAL HISTORY - CHILD

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Is the patient suffering from (or have you ever had) any of the following?

Rheumatic fever

Heart Disease / Heart Murmur

Stroke

High/Low blood pressure

Diabetes

Fits/ Epilepsy/Fainting/Dizziness

Asthma- Mild, Moderate, Severe

Rheumatism

HIV/AIDS

Hepatitis

Any blood disorder

Joint problems /replacement

Disorder of the stomach, bowel or digestive system

Cancer/Tumors (Benign/ Malignant)

Osteoporosis

Yes No Yes No Yes No Yes No

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