New Patient Step 7

Ultrasmile/New Patient Step 7

Do you have or ever had

Hospitalisation for illness or injury
YesNo



Heart Problems
YesNo

Heart Murmur
YesNo

Rheumatic Fever
YesNo

Scarlet Fever
YesNo

High Blood Pressure
YesNo

Low Blood Pressure
YesNo

A Stroke
YesNo

Artificial Prosthesis (i.e. heart valve)
YesNo

Anaemia or other blood disorder
YesNo

Prolonged bleeding due to a slight cut
YesNo

Emphysema
YesNo

Tuberculosis
YesNo

Asthma
YesNo

Breathing or sleep problem (i.e. snoring, sinus)
YesNo

Kidney Disease
YesNo

Liver Disease
YesNo

Jaundice
YesNo

Thyroid or parathyroid disease
YesNo

Hormone deficiency
YesNo

High Cholesterol
YesNo

Diabetes
YesNo

Stomach or Duodenal Ulcer
YesNo

Digestive Disorders (i.e. gastric reflux)
YesNo

Osteoporosis/osteopenia
YesNo

Arthritis
YesNo

Glaucoma
YesNo

Contact Lenses
YesNo

Head or Neck Injuries
YesNo

Epilepsy
YesNo

Convulsions (seizures)
YesNo

viral infections and cold sores
YesNo

Any lumps or swelling in the mouth
YesNo

Hives, skin rash, hay fever
YesNo

Venereal Disease
YesNo

Hepatitis
YesNo

HIV/AIDS
YesNo

Tumour, Abnormal Growth
YesNo

Radiation Therapy
YesNo

Chemotherapy
YesNo

Emotional Problems
YesNo

Psychiatric Treatment
YesNo

Antidepressant Medication
YesNo

Alcohol/Drug Dependency
YesNo

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