GESONDHEIDSVRAELYS / HEALTH QUESTIONNAIRE

    Pasient se Naam en Van / Patient's Name and Surname:

    Ouerdom / Age:

    Geslag/ Gender:

    Ly u aan enige van die volgende toestande? / Have you ever had any of the following conditions?

    Hartsiektes / Heart Disease

    Hooikoors / Hay fever

    Hepatitis B

    Bloedings neiging / Excessive bleeding

    Epilepsie / Epilepsy

    Rumatiekkoors / Rheumatic fever

    Gewrigsonsteking / Arhritis

    Longaandoenings / Lung problems

    Is u MIV Positief /Are you HIV Positive

    Mangels/Adenoide verwyder / Tonsils/Adenoids removed

    Diabetes

    Hormonale probleme / Hormonal problems

    Tuberkulose / Tuberculosis

    Geelsug of lewer probleme / Jaundice or liver problems

    Asma / Asthma

    Beensiekte /Bone disorder

    Endokriene afwykings / Endocrine disorders

    Allergië / Allergies

    ADHD / ADD

    Kanker / Cancer

    Temporomandibulêre gewrigs probleme / Temporomandibular joint condition

    Gebruik u tans of het u onlangs enige medikasie gebruik? / Do you currently or have you recently been
    using any medication?

    Spesifiseer indien "Ja" aangedui / Specify if indicated "Yes":

    Ouderdom waarop mangels/adenoiede verwyder is / Age when tonsils/ adenoids were removed (Jaar / Years)

    Ouderdom waarop eerste melktand verskyn het / Age of eruption of first tooth (Jaar / Years)

    Het u enige gesigsnykunde ondergaan? / Have you had any facial surgery?

    Indien wel, besonderhede / If so, details:

    Enige beserings of trauma aan kake of tande? / Any injuries or trauma to jaws or teeth?

    Indien wel, besonderhede / If so, details:

    Het u enige spraak probleme? / Do you have any speech problems?

    Indien wel, besonderhede / If so, details:

    Is u 'n mondasemhaler? / Are you a mouth breather?

    Het u u duim of vingers gesuig? / Did you suck a thumb or fingers?

    Indien wel,tot watter ouderdom / If so, till what age?

    Het 'n tandarts al enige tande verwyder? / Were any teeth removed by a dentist?

    Is u bewus van enige afwesige of ekstra permanente tande? / Any missing teeth or extra permanent teeth?

    Het u al van tevore 'n ortodontis gekonsulteer? / Have you previously consulted an orthodontist?

    Is u gemotiveerd om ortodontiese behandeling te ondergaan? / Are you motivated to undergo orthodontic treatment?

    Enige familielid wat tans of vroeër ortodontiese behandeling ondergaan het? / Any family member that are
    currently or previously being treated orthodontically?

    Indien wel, besonderhede / If so, details:

    Is u bewus van gewoontes soos tande klem of kners? / Are you aware of clenching or grinding of teeth?

    Enige ander inligting van belang / Any further information relevant

    Ek verklaar dat ek die bogenoemde mediese geskiedenis deur gelees het, en dat dit volgens my meening akkuraat is. In die
    geval van toekomstige veranderinge, sal ek die praktyk dien ooreenkomstig verwittig .

    I hereby certify that I have reviewed the above medical history and it is accurate to my knowledge. If there are any future
    changes in this information , I will inform this practice of these changes.

    Datum / Date


    Handtekening van persoon wat die
    gesondheidsvraelys voltooi /
    Signature of person completing the
    health questionanaire


    Verwantskap / Relationship