CONFIDENTIAL MEDICAL HISTORY
PERSONAL DETAILS
Title
*
Mr
Mrs
Ms
Miss
Number/ Name. Road, Town
Name
*
First Name
Last Name
Date of Birth:
*
/
Day
/
Month
Year
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Home Address:
*
Number/ Name, Road/ Street, Town
Postcode
*
Telephone (Home):
*
Code Number
Telephone (Work):
*
Code Number
Mobile:
*
Occupation:
*
Email:
*
example@example.com
Emergency contact: Name
*
Contact No.
*
Relationship:
*
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MEDICAL HISTORY
Name of GP, address, telephone:
*
Do you have allergy to penicillin, sleeping tablets, local anaesthetics, codeine, latex or other drugs or medicines?
*
Yes
No
Please explain:
Tick any of the following, which you have had:
*
High Blood Pressure
Hepatitis
Artificial Joint Replacement
Arthritis
Heart Murmur
Jaundice
Bleeding Disorders
Anaemia
Cardiac Pacemaker
Diabetes
Ulcers
Rheumatic Fever
HIV
Any Lung Trouble (TB, astham)
None of the above
Have you ever had any other serious illness?
*
No
Yes
Please detail:
Women: If pregnant, please state number of months:
Are you currently taking any medicines?
*
Yes
No
Please list name, dosage and frequency:
Have you ever had an unusual reaction to dental anaesthesia or general anaesthesia?
*
Yes
No
Have you had any eye trouble recently?
*
Yes
No
Does your mouth feel dry or do you have a burning sensation of lips or tongue?
*
Yes
No
Have you taken or been given injections of steroids such as cortisone?
*
Yes
No
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DENTAL HISTORY
Have you come here for the relief of pain?
*
Yes
No
Please give details:-
Have you been treated for periodontal disease (gum disease)?
*
Yes
No
Do you have sores, swellings, or blisters on your gums, cheeks or lips? Eg Cold sores?
*
Yes
No
Have you had orthodontic treatment to straighten your teeth?
*
Yes
No
How would you describe your teeth colour? Where 1 is poor and 5 is excellent
*
1
2
3
4
5
Do you like your smile?
*
Yes
No
If no, why?
How nervous do you feel in the dental surgery? Where 1 is very and 5 is not at all
*
1
2
3
4
5
How many units of alcohol do you drink per week?
*
A unit is ½ a pint of lager, a single measure of sprits or ½ a glass of 175ml wine
Do you smoke?
*
Yes
No
Past
How many per day?
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As per the new GDPR regulations, please indicate if we can contact you with practice promotions and notifications
*
Yes
No
Patient Signature:
*
Please use your finger or mouse to sign
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Date:
*
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Month
/
Day
Year
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