Torque Orthodontics :: 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

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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

Please note that we only treat you according to the information you have provided for us.

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