Medical History Questionnaire - Dentaprime F3T [long]

  • Medical History Form

    Click the link below to start the questionaire

    >> https://form.jotform.com/203072141758047 <<

  • Medical History Form

    Please, fill out your medical information carefully. For the best user experience, please use a desktop computer, laptop, or tablet when answering the questions below.

    It is very important for our Clinic and professional to understand your medical needs before any examination or treatment is carried out. Any information given to us is a strictly confidential.

  • Your Title*

  • Are you pregnant?

  • Details of a contact in case of emergency

  • Title*

  • Next of kin

  • Title*

  • GP Contact Details

  • Medical History

  • Please answer the questions below concerning your health condition as precise as possible. Your answers will remain confidential in accordance with the Data Protection Act.

  • Have you been hospitalized in the last 12 months?*
  • Are you taking or have you taken steroids in the last 2 years?*
  • Have you had a prolonged illness or been hospitalized?*
  • Have you had any major/serious operation?*

  • Heart/blood circulation conditions

  • Stroke*
  • Heart attack*
  • Heart murmur*
  • Heart Pacemaker*
  • Heart operation*
  • Heart valve condition*
  • Infectious diseases
  • HIV / AIDS*
  • Hep A*
  • Hep B*
  • Hep C*
  • Tuberculosis*
  • Allergies
  • To local anaesthetic*
  • To pain killers*
  • To other medication*
  • To plastic (p.e. latex)*
  • To metal*

  • Other Conditions

  • Seizure disorder*
  • Angina*
  • High blood pressure*
  • Low blood pressure*
  • Osteoporosis*
  • Rheumatic fever*
  • Blood clotting disorder*
  • Drug addiction*
  • Under-active thyroid*
  • Asthma*
  • COPD*
  • Hayfever*
  • Diabetes*
  • Kidney disease*
  • Epilepsy*
  • Glaucoma*
  • Arthritis*
  • Mental disorder*
  • Do you have cancer?*
  • Stomach Hernia*
  • Do you have pharyngeal reflex known as gag reflex*
  • Have you ever had any ill affects following dental treatment?*
  • Do you have severe bleeding/bruising problem?*
  • Do you have the habit of grinding or clenching?*
  • Do you smoke?*
  • Do you drink alcohol?*
  • Do you have a dental phobia?*
  • Have any complications occurred during operations?*
  • Have you got implants in your body? (incl. dental)*
  • Have you got periodontists or have you been treated for it?*
  • Please confirm:*
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  • Should be Empty: