Medical History Form

Confidential Medical History Form

Shiraz, 389 Warwick Road, Solihull
West Midlands, B91 1BJ
Tel: 0121 709 1660

Like all dentists, we ask patients for information about their general health to help us treat them safely. Please complete this form, which Dr Vahdaty will discuss fully with you before commencing treatment. If you have any questions, please ask Dr Vahdaty. All information will be kept completely confidential. Thank you.

Title *

Name *

First Name Surname

Email *

ARE YOU CURRENTLY *

YES

NO

GIVE DETAILS?

Receiving treatment from a Doctor, Hospital, or Clinic? Carry a warning card?

Taking any prescribed medicines (tablets, ointments, injections, inhalers)?

Allergic to any medicines, foods, or materials, in particular to penicillin or rubber (latex)?

Pregnant?

DO YOU SUFFER FROM *

YES

NO

GIVE DETAILS?

Hay fever?

Cold sores, eczema or arthritis?

Bronchitis, asthma or other chest conditions?

Fainting attacks, giddiness, blackouts or Epilepsy?

Heart problems, angina, blood pressure problems or stroke?

Have a pacemaker, or have you had any form of heart surgery?

Diabetes (or does anyone in your family)?

Bruising or persistent bleeding following injury, tooth extraction, or surgery?

Any infection diseases (including HIV and hepatitis)?

DID YOU AS A CHILD OR SINCE, HAVE *

YES

NO

GIVE DETAILS?

Rheumatic fever or chorea?

Liver disease (jaundice, hepatitis) or kidney disease or any other serious illness?

Blood refused by the blood transfusion service?

A bad reaction to general or local anesthetic?

Joint replacement or other implants?

A close relative with Creutzfeldt Jakob Disease (CJD)?

Have you or a close relative shown any signs/symptoms of Covid-19?

GP's DETAILS

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City County

Post Code Country

Tel. Number *

Data Protection (GDPR) - I consent for my information to be shared in accordance with the practice's GDPR policy if necessary, with consent *

YES NO

Completed by: *

Self Parent Guardian

Signature *

Clear

Date *

MEDICAL HISTORY UPDATE

Have here been any changes in your medical history since your last course of treatment?