Tel: 0117 9238 400 Fax: 0117 9467 007 Email: info@rootfillings.com

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  • Section 1

  • Section 2

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    • Don't know:
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  • Section 3

    • High blood pressure:
    • Heart murmur or prolapsed valve:
    • Joint prosthesis (hip, knee, etc):
    • Rheumatic fever or rheumatic heart disease:
    • Congenital heart disease:
    • Cardiovascular disease: heart attack, stroke or bypass:
    • Prosthetic heart valve:
    • Blood disorder (e.g. anemia):
    • Venereal disease:
    • Asthma:
    • Allergy to latex:
    • Low blood pressure:
    • Chest pain, angina:
    • Swollen ankles, arthritis or joint disease:
    • Cardiac pacemaker:
    • Heart surgery:
    • Delay in healing:
    • Tuberculosis:
    • Emphysema:
    • X-ray treatment or chemotherapy:
    • On a diet:
    • History of alcohol abuse:
    • Eye disease or glaucoma:
    • Infectious mononucleosis:
    • Sinus trouble:
    • Thyroid problems:
    • Diabetes:
    • Stomach ulcers, colitis:
    • Hepatitis, jaundice, liver disease:
    • Psychiatric treatment:
    • Fainting spells or seizures:
    • Epilepsy:
    • Cancer:
    • Temporomandibular joint problems (TMJ):
    • Low blood sugar:
    • Dialysis:
    • Irregular heart beat:
    • Contagious diseases:
    • Bronchitis, chronic cough:
    • Hay fever or sinus problems:
    • Problems with the immune system:
    • Difficult breathing or other lung trouble:
    • Chronic fatigue or night sweats:
    • History of drug abuse:
    • Wear contact lenses:
    • Bruise easily:
    • Gall bladder trouble:
    • None of the above:
  • Section 4

    • Yes:
    • No:
    • Don't know:
    • Yes:
    • No:
    • Yes:
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  • Section 5: Women only

    • Yes:
    • No:
    • Yes:
    • No:
    • Yes:
    • No:
  • NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gyneacologist for assistance regarding additional methods of control.
    • Yes:
    • No:
    • Yes:
    • No:
  • Confirmation

    • I agree:
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