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MEDICAL HISTORY FORM

To provide the best and safest treatment, your dentist needs to know of any problems which may effect your treatment.

By submitting your details, you agree to the terms and conditions detailed in our privacy policy* surrounding data protection and use of personal data.

    Title:

    Full Name:

    Sex:

    Date of Birth:

    Address:

    What is your reason for attending the practice:

    Please provide further Details if required:

    Postcode:

    Phone Number:

    Your email address:

    Occupation:

    When did you last receive dental treatment?

    Doctors name:

    Doctors Address:

    Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
    YesNo

    Please provide Details:

    Are you taking any medicines, tablets, drugs or injections or using any cream, ointments or inhalers?
    YesNo

    Please provide Details:

    Are you taking or have you taken steroids in the last 2 years?
    YesNo

    Please provide Details:

    Are you allergic to penicillin?
    YesNo

    Please provide Details:

    Are you allergic to any medicines, foods or materials?
    YesNo

    Please provide Details:

    Do you carry a warning card?
    YesNo

    Please provide Details:

    Are you pregnant or a nursing mother?
    YesNo

    Please provide Details:

    Are you HIV positive?
    YesNo

    Please provide Details:

    Have you had rheumatic fever or chorea?
    YesNo

    Please provide Details:

    Have you had jaundice, liver or kidney disease or hepatitis?
    YesNo

    Please provide Details:

    Have you ever had a stroke?
    YesNo

    Please provide Details:

    Did you as a child or since have brain surgery, growth hormone treatment before the mid 1980’s or have a close relative with Creutzfeldt Jakob Disease?
    YesNo

    Please provide Details:

    Have you ever been told you have a heart murmur, heart problem, angina or high blood pressure?
    YesNo

    Please provide Details:

    Have you ever had your blood refused by the Blood Transfusion Service?
    YesNo

    Please provide Details:

    Have you ever had a bad reaction to a local or general anaesthetic?
    YesNo

    Please provide Details:

    Have you had a joint replacement or other implant?
    YesNo

    Please provide Details:

    Have you been hospitalised for any reason?
    YesNo

    Please provide Details:

    Do you have arthritis?
    YesNo

    Please provide Details:

    Do you have a pacemaker or have you had heart surgery?
    YesNo

    Please provide Details:

    Do you suffer from hay fever, eczema, or any other allergy?
    YesNo

    Please provide Details:

    Do you suffer from bronchitis, asthma, or chest infection?
    YesNo

    Please provide Details:

    Do you have fainting attacks, giddiness, blackouts or epilepsy?
    YesNo

    Please provide Details:

    Do you have diabetes or does anyone in your family?
    YesNo

    Please provide Details:

    Do you bruise easily or suffer persistent bleeding following a tooth extraction?
    YesNo

    Please provide Details:

    Do you think there are any other aspects, concerning your health, that your dentist should know?
    YesNo

    Please provide Details:

    On average, how many of the following do you have on a daily basis?

    Cigarettes:
    Alcoholic Drinks:

    Additional Comments