Medical History Form

Patient Details

Please provide us with information about your personal details and general health to help us treat you safely.

Title:

First Name:

Surname:

Sex:

Date Of Birth

Your Address

Address - First Line

Address - Second Line

Town/County

Postcode

Contact Details

Email:

Telephone (Daytime):

Telephone (Mobile):

GP Name & Address:

GP Telephone:

Medical History (Part 1)

Are you currently

Pregnant?

Yes No

Receiving treatment from a doctor, hospital or clinic?

Yes No

Taking any prescribed medicines (e.g. tablets, ointments, injections?

Yes No

Taking inhalers, eyedrops, suppositories, nebulisers, the contraceptive pill or HRT)?

Yes No

Carrying a medical warning card?

Yes No

If you have answered Yes to any of the above, please provide more details below:

Medical History (Part 2)

Do you suffer from

Allergies to any medicines (e.g. penicillin), substances (e.g. latex/rubber or foods)?

Yes No

Hay fever or eczema?

Yes No

Bronchitis, asthma or other chest condition?

Yes No

Fainting attacks, giddiness, blackouts, epilepsy?

Yes No

Muscle problems (e.g. myopathy, dystrophy, paralysis)?

Yes No

Heart problems (e.g. angina, blood pressure problems or Heart problems (e.g. angina, blood pressure problems or stroke)?

Yes No

Diabetes (or does anyone in your family)?

Yes No

Neurological (nerve) diseases (e.g. ‘neuropathies’, MS etc.)?

Yes No

Arthritis?

Yes No

Bruising or persistent bleeding following injury, tooth extraction or surgery?

Yes No

Any infectious diseases (including HIV, hepatitis, TB)?

Yes No

Stomach ulcers/hiatus hernia/indigestion?

Yes No

If you have answered Yes to any of the above, please provide more details below:

Medical History (Part 3)

Did you, as a child or since, have

Rheumatic fever, heart murmur or chorea?

Yes No

Liver disease (e.g. jaundice, hepatitis)?

Yes No

Kidney disease?

Yes No

Have Blood refused by the Blood Transfusion Service?

Yes No

A bad reaction to general or local anaesthetic?

Yes No

A joint replacement or other implant?

Yes No

Treatment that required you to be in hospital?

Yes No

Heart surgery?

Yes No

Brain surgery?

Yes No

Growth hormone treatment before the mid 1980s?

Yes No

A close relative (parent, sibling, child, grandparent or grandchild) with Creutzfeldt Jakob Disease (CJD)?

Yes No

Steroid treatment?

Yes No

Any other serious illness?

Yes No

If you have answered Yes to any of the above, please provide more details below:

Further Details

How many units of alcohol do you drink per week?

Do you smoke any tobacco products now?

Yes No

Do you smoke any tobacco products now (or did you in the past)?

Yes No

If you answered Yes to the above question, how many times per day?

Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?

Yes No

If you answered Yes to the above question, how many times per day?

Please give any other details which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin).

Completed by

Self Parent Guardian Dentist

I understand a minimum of 48 hours notice must be given to change or cancel an appointment. Failure to provide us with 48 hours advance notice or failure to present for a scheduled appointment will result in a cancellation or no-show fee.

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Patient Details

Your Address

Contact Details

Medical History (Part 1)

Medical History (Part 2)

Medical History (Part 3)

Further Details

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