Medical History Form

We ask you for information about your general health to help us treat you safely. Please complete the form and press send. All information will be kept confidential by the people caring for you.

Name
Title
Date Of Birth:
Sex:  male female
Doctors Name:
Doctors Address:
Are you currently : Give details:
Attending or receiving treatment from a doctor,hospital or specialist?  yes no
Taking any medicines from your doctor? (Tablets,
Ointments, injections or inhalers, including
Contraceptives and hormone replacement therapy?)		  yes no
Allergic to any medicines or substances?  yes no
Pregnant?  yes no
Have you: Give details:
Had rheumatic fever?  yes no
Ever been told you had a heart problem or heart
attack, angina or blood pressure issues?		  yes no
Had any blood tests or inoculations?  yes no
Had your blood refused by the blood transfusion
service?		  yes no
Had a bad reaction to local or general anaesthetic?  yes no
Had a joint replaced?  yes no
Been hospitalised?  yes no
Do you: Give details:
Have arthritis?  yes no
Have a pacemaker. Or had any form of heart
surgery??		  yes no
Suffer from hayfever, eczema or other allergy?  yes no
Suffer from bronchitis, asthma or other chest
condition?		  yes no
Have fainting attacks, giddiness, blackouts or epilepsy?  yes no
Have diabetes or does anyone in your family?  yes no
Bruise easily following a tooth extraction, injury or surgery?  yes no
Carry a medical warning card?  yes no
Ever get cold sores?  yes no
Had jaundice, liver, kidney disease or hepatitis?  yes no
Smoking:
Do you smoke any tobacco products now or in the past?  yes no in past
Drinking:
How many units of alcohol do you drink per week? Units per week
Please give any other details which your dentist might need to know about
Completed by (please tick)  Self Parent Guardian