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Medical History Form

    High risk - Frontline health worker or carer or confirmed case of Covid 19 in your own householdModerate risk - Keyworker in contact with the public, but have had no symptoms or exposure to someone who has been infected.Low risk - Have been isolating alone or with household and with minimum public contact. No known cover 19 exposure.Have had Covid 19 and recovered, and this was confirmed by testing and documentationHave an underlying Health condition that puts you in a Vulnerable category

    Has anyone in your household tested positive for Covid 19?
    YesNo
    Is anyone isolating your household?
    YesNo


    Shortness of breath or difficulty in breathing, that is new or different than before
    YesNo
    New and persistent cough
    YesNo
    Temperature over 37.8 celsius/100 fahrenheit or a Fever
    YesNo
    Unexplained tiredness/lethargy
    YesNo
    Loss of taste or smell
    YesNo
    Muscles aching, that is new to you
    YesNo
    Stomach upset problems that are new to you
    YesNo
    Are you over 70 years old?
    YesNo


    Are you currently receiving treatment from a doctor, hospital or clinic?
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    Do you carry a Medical warning card?
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    Are you diabetic (or is anyone in your family)?
    YesNo
    Do you suffer from any allergies to medicines (e.g. penicillin), food or substances (e.g. latex/rubber)?
    YesNo
    Do you suffer from Hayfever/Eczema?
    YesNo
    Do you suffer from Bronchitis, asthma or other chest conditions?
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    Do you suffer from fainting attacks, giddiness, blackouts or Epilepsy?
    YesNo
    Do you suffer from Heart problems, Angina, blood pressure problems or Stroke?
    YesNo
    Do you suffer from Arthritis?
    YesNo
    Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
    YesNo
    Do you suffer from any infectious diseases (including HIV and Hepatitis)
    YesNo
    Have you ever had Rheumatic fever or Chorea?
    YesNo
    Have you ever had Liver disease (e.g. jaundice,hepatitis) or kidney disease?
    YesNo
    Have you ever had blood refused by the Blood transfusion service?
    YesNo
    Have you ever had a bad reaction to a general or local anaesthetic?
    YesNo
    Have you ever had joint replacement or other implant?
    YesNo
    Have you ever had treatment that required you to be in hospital?
    YesNo
    Do you have any close relatives with Creutzfeldt Jacob disease (mad cow disease)?
    YesNo
    Have you ever had Heart surgery?
    YesNo
    Have you ever had Brain surgery?
    YesNo

    Do you Vape with an E-Cig?
    YesNo

    To apply to register with tooth+ Stirling please follow the link...

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    Tooth+
    1 Munro Road
    Stirling
    FK7 7UU

    Tel: 01786 231123

    Email: welcome@toothplus.co.uk

    Last Updated: June 22, 2022 - 9:39 pm

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      • Dental Team
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      • General Dentistry
      • Dental Checkups
      • Dental Hygiene
      • Dental Implants
      • Cosmetic Dentistry
      • Tooth Whitening
      • Invisible Braces
    • Implants
      • Single Dental Implants
      • Implant Retained Dental Bridges
      • Implant Retained Dentures
      • Dental Implant FAQ’s
    • Invisible Braces
    • Rejuvenation
    • Dental Anxiety
    • Fees
    • News
    • Contact
    • Emergency
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