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