document.writeln('\r\n \r\n \r\n \r\n \r\n \r\n

<\/font><\/font><\/font>Broadmead\r\n Dental Practice \r\n Medical Questionnaire - Strictly Confidential<\/font><\/b><\/font><\/td>\r\n <\/tr>\r\n
<\/td>\r\n	<\/td>\r\n	<\/td>\r\n	<\/td>\r\n <\/tr>\r\n \r\n
Surname<\/font><\/td>\r\n	\r\n \r\n <\/td>\r\n	Forename(s)<\/font><\/td>\r\n	\r\n \r\n <\/td>\r\n <\/tr>\r\n
Title<\/font><\/td>\r\n	\r\n \r\n <\/td>\r\n	Occupation<\/font><\/td>\r\n	\r\n \r\n <\/td>\r\n <\/tr>\r\n
Address<\/font><\/td>\r\n	\r\n <\/textarea>\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Postcode<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" name="postcode" size="20" maxlength="100">\r\n <\/font><\/td>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Date of\r\n Birth<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" name="dob" size="20" maxlength="100">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Work Number<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" name="work_number" size="20" maxlength="100">\r\n <\/font><\/td>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Mobile\r\n Number<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" name="mobile_number" size="20" maxlength="100">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Phone Number<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" name="phone_number" size="20" maxlength="100">\r\n <\/font><\/td>\r\n <td width="30%"><font face="Arial, Helvetica, sans-serif" size="2">Email Address<\/font><\/td>\r\n <td width="20%"> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="email">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td width="30%"> <\/td>\r\n <td width="20%"> <\/td>\r\n <td width="30%"> <\/td>\r\n <td width="20%"> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2" width="50%"><font face="Arial, Helvetica, sans-serif" size="2">Date\r\n last dental treatment was received<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"> <\/font><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="last_treatment_date">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Doctors\r\n Name and Address<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">\r\n <textarea cols="20" name="doc_name_address"><\/textarea>\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">How did\r\n you hear about the practice?<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="heard_from">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Do you\r\n have any other family members registered at our practice?<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="family_members">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">What is\r\n your main reason for attending today?<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="reason_attending">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Is there\r\n anything about your smile you\'d like to change?<\/font><\/td>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="smile_change">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2"><b>ARE YOU:<\/b><\/font><\/td>\r\n <td> <\/td>\r\n <td>\r\n <div align="center"><font face="Arial, Helvetica, sans-serif" size="1">Choose<\/font><\/div>\r\n <\/td>\r\n <td>\r\n <div align="center"><font face="Arial, Helvetica, sans-serif" size="1">(if\r\n yes please give details)<\/font><\/div>\r\n <\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Receiving\r\n treatment from a doctor, hospital, clinic?<\/font><\/td>\r\n <td> <font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="receiving_treatment" value="Yes">\r\n Y\r\n<input type="radio" name="receiving_treatment" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="receiving_treatment_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Taking\r\n ANY medicines from your doctor?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="doctor_medicines" value="Yes">\r\n Y\r\n <input type="radio" name="doctor_medicines" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="doctor_medicines_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Taking\r\n or have taken steriods in the last 2 years?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="taken_steriods" value="Yes">\r\n Y\r\n <input type="radio" name="taken_steriods" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="taken_steriods_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Allergic\r\n to any medicines, foods, materials?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="allergies" value="Yes">\r\n Y\r\n<input type="radio" name="allergies" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="allergies_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">A nursing\r\n or expectant mother, (please give date of birth)<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="mother" value="Yes">\r\n Y\r\n <input type="radio" name="mother" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="mother_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2"><b>HAVE YOU:<\/b><\/font><\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Had rheumatic\r\n fever or cholera?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="fever" value="Yes">\r\n Y\r\n <input type="radio" name="fever" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="fever_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Had jaundice,\r\n liver, kidney disease, hepatitis?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="jaundice" value="Yes">\r\n Y\r\n <input type="radio" name="jaundice" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="jaundice_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Ever had\r\n a problem with your heart?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="heart" value="Yes">\r\n Y\r\n <input type="radio" name="heart" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="heart_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Ever had\r\n a problem with your blood pressure?<\/font><\/td>\r\n <td>\r\n <p><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="blood_pressure" value="Yes">\r\n Y\r\n <input type="radio" name="blood_pressure" value="No">\r\n N<\/font><\/p>\r\n <\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="blood_pressure_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Had any\r\n recent or relevant blood tests?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="bloodtests" value="Yes">\r\n Y\r\n <input type="radio" name="bloodtests" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="bloodtests_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Had a bad\r\n reaction to local or general anaesthetic?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="anaesthetic" value="Yes">\r\n Y\r\n <input type="radio" name="anaesthetic" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="anaesthetic_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Had a joint\r\n replacement?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="jointreplacement" value="Yes">\r\n Y\r\n <input type="radio" name="jointreplacement" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="jointreplacement_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Do you smoke? If yes, please state how many per day.<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="smoke" value="Yes">\r\n Y\r\n <input type="radio" name="smoke" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="smoke_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2"><b>DO YOU<\/b><\/font><\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Have arthritis\r\n or other joint problems?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="arthritis" value="Yes">\r\n Y\r\n <input type="radio" name="arthritis" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="arthritis_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Suffer\r\n from hayfever, eczema or any other allergy?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="hayfever" value="Yes">\r\n Y\r\n <input type="radio" name="hayfever" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="hayfever_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Suffer\r\n from fainting attacks or epilepsy?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="fainting" value="Yes">\r\n Y\r\n <input type="radio" name="fainting" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="fainting_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Suffer\r\n from bronchitis, asthma or other chest condition?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="asthma" value="Yes">\r\n Y\r\n <input type="radio" name="asthma" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="asthma_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Have diabetes\r\n or other member of your family?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="diabetes" value="Yes">\r\n Y\r\n <input type="radio" name="diabetes" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="diabetes_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Bruise\r\n or bleed easily following a tooth extraction?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="bruise" value="Yes">\r\n Y\r\n <input type="radio" name="bruise" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="bruise_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Carry a\r\n health warning card, SOS bracelet etc?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="healthwarning" value="Yes">\r\n Y\r\n <input type="radio" name="healthwarning" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="healthwarning_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Ever get\r\n cold sores?<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="coldsores" value="Yes">\r\n Y\r\n <input type="radio" name="coldsores" value="No">\r\n N<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="coldsores_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2">Are there\r\n any other details we should be informed of?<\/font><\/td>\r\n <td>\r\n <p><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="radio" name="otherinfo" value="Yes">\r\n Y\r\n <input type="radio" name="otherinfo" value="No">\r\n N<\/font><\/p>\r\n <\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="otherinfo_details">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">Your Name:<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="signature">\r\n <\/font><\/td>\r\n <td align="center"><font face="Arial, Helvetica, sans-serif" size="2">Date<\/font><\/td>\r\n <td><font face="Arial, Helvetica, sans-serif" size="2">\r\n <input type="text" size="20" maxlength="100" name="signature_date">\r\n <\/font><\/td>\r\n <\/tr>\r\n <tr>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <td> <\/td>\r\n <\/tr>\r\n <tr>\r\n <td colspan="4" align="center">\r\n <input type="submit" name="Submit" value="Submit">\r\n <\/td>\r\n <\/tr>\r\n<\/form>\r\n<\/table>');