Medical History Form

Medical History Form

Please complete every section of this form to provide your dentist with all the medical information they will require to care for you appropriately.
Patient's Name*

First NameLast Name
Address*
Date of birth*

DayMonthYear
Home Phone*
Mobile Phone
Email
example@example.com
Doctor's Name*
Practice Name*
Practice Phone
Emergency Contact*
Emergency Phone*
Relationship to patient

Do you

have or have you had any of the following conditions? (tick all that apply)
Heart Problems :-*

Rheumatic FeverHigh Blood PressureHeart SurgeryPacemaker FittedHeart MurmurThrombosisNone
Other Heart Conditions:

Do you

have or have you had any of the following conditions? (tick all that apply)
Chest Problems :-*

BronchitisEmphysemaPneumoniaChest SurgerySmokerCystic FibrosisPleurisyNone
Other Chest Conditions:

Do you

have or have you had any of the following conditions? (tick all that apply)
Blood Problems :-*

BleedingHepatitis BH.I.V.AnaemiaAbnormal Blood TestSickle CellHaemophiliaTBNone
Other Blood Conditions :-

Do you

have or have you had any of the following conditions? (tick all that apply)
Other issues :-*

Serious Childhood IllnessDiabetesLiver Disease.Kidney DiseaseEpilepsyCancerG.A. ExperienceHiatus HerniaNone
Other Conditions :-

Do you

have or have you had any of the following conditions? (tick all that apply)
Allergies :-*

PenicillinHay FeverAnti-Tetanus Serum.EczemaAspirinAsthmaticLatex AllergyNone
Other Allergy Conditions :-

Do you

have or have you had any of the following conditions? (tick all that apply)
Warnings :-*

Reaction to local anaesthetic?Anti biotic cover required?Problem being reclined?.Are you pregnant?Do you carry a warning card?Artificial or prosthetic joint?None
What special precautions should we take?

List any medications you're taking :-
Units of alcohol per week
Signed by:*

Clear
Please use your mouse, or finger, to draw your signature in the box
Date:

DayMonthYear
Date
Should be Empty: