Are you:

having any medical treatment at the moment? YesNo

taking any medicines, drugs or pills? YesNo

taking steroids (or have you taken them in the past)? YesNo

taking anti-coagulants? YesNo

pregnant? YesNo

Have you:

had rheumatic fever? YesNo

had any major operations or illnesses? YesNo

had jaundice or hepatitis? YesNo

had positive blood test results for hepatitis A or B, or HIV? YesNo

reacted adversely to local or general anaesthesia? YesNo

had a hip or other joint replacement? YesNo

Do you have now, or have you ever had, problems with:

your heart? YesNo

your lungs or chest? YesNo

your liver or kidneys? YesNo

fainting? YesNo

Do you:

smoke? (how many per day?) YesNo

have a pacemaker? YesNo

have any allergies? YesNo

have an allergy to latex? YesNo

have asthma? YesNo

have epilepsy? YesNo

get cold sores? YesNo

have diabetes? (does a family member?) YesNo

your doctor’s name:

for a child, the parents/guardians name(s):

Contact Us

Tel: 0203 1967326

Email: ask@londonbracesclinic.co.uk

31 Harley St, Marylebone, London

Opening hours

Monday to Friday
8.00am–8.00pm

Saturdays
9.00am–5.00pm

Sundays by appointment