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GESONHEIDSVRAELYS VAN PASIëNT / HEALTH QUESTIONAIRE OF PATIE
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* Required information.
Geboorte Abnormaliteite / Birth Abnormalities or injuries *
Ondergaan u tans mediese behandeling / Are you undergoing medical treatment *
Waarvoor / What for
Rumatiekkoors / Rheumatic fever *
Years
Hartkwaal / Heart disease *
Years
Geelsug / Jaundice (hepatitis) *
Years
Suikersiekte / Diabetes *
Years
Het u as ‘n kind hoë koors gehad / Did you ever have a high feaver as a child *
Asma / Asthma *
Hooikoors / Hay fever *
Toeneus / Blocked nose *
Allergië / Allergies *
Is u mangels en/of adenoide verwyder / Are your tonsils and/or adenoids removed *
Year
Lip operasie/s gehad / Surgery of the lip/s *
Year
Ander gesigsnykunde / Other facial surgery *
Year
Beserings aan die gesig of tande / An injury to the face or teeth *
Year
Was of is daar ‘n duimsuig gewoonte / Was or is there a thumbsucking habit *
Years
Enige van u melktande vroeg verwyder /Have any of your milk teeth been extracted *
Vorige ortodontiese behandeling / Previous orthodontic treatment *
Year
Familie geskiedenis / Family history *
V.I.G.S. risiko / A.I.D.S. risk *
Is u al getoets vir H.I.V. antiliggame / Have you been tested for H.I.V. *
Indien JA / If YES:

Address

321 Bulwer Street
Central CBD
Pietermaritzburg
3201

Appointments

E-mail: orthodontist@sainet.co.za
Telephone: 033 394 7635

Appointments can be made daily from Monday to Friday 08:00 to 16:30. You may also leave a message at any time for us to contact you on our answering service.

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