Confidential Medical History The Dental Clinic, Portishead
It is important that you complete this form in full
Full Name
*
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Address
Phone number
Email address
Doctors name
Doctors address
Contact number
Who should we contact in an emergency
Please include an emergency contact name, phone number and relationship
Do you have a persistant cough or a fever, temperature over 37.8?
Yes
No
Have you been in contact with anyone in the last 14 days that has/had the COVID19 virus?(including any family members)
Yes
No
Have you or any family members been told to self isolate in the last 14 days?
Yes
No
In the last 14 days, have you had any other symptoms related to COVID19?
Yes
No
If yes, please specify your symptoms below
Please insert N/A if you have no symptoms
According to government guidence, would you consider yourself to be either vulnerable, medically comprimised or shielding at home during lockdown (including any family members)?
Yes
No
Heart
*
Rheumatic Fever
Cardiac Disease
Angina
Thrombosis
Other Heart condition
Heart Murmur
High Blood Pressure
Heart Surgery
Pace Maker fitted
None
Other
If you have ticked other heart conditions please give details:
If you have selected none please insert N/A in the box above
Blood
*
Hepatitis B
Anaemia
Sickle Cell
Abnormal Blood test
HIV
Haemophilia
Other Blood condition
Blood refused by blood transfusion service
None
If you have ticked other blood conditions please give details:
If you have selected non, please insert N/A in the box above
Allergies
Penicillin
Hayfever
Anti Tetanus Serum
Eczema
General Anaesthetic
Local Anaesthetic
Latex Allergy
Medicine
Plants
Food
Aspirin
Other Allergy
None
If you have ticked any allergies above please give details:
If you selected none , please insert N/A in the box above
Chest
Bronchities
Emphysema
Chest Surgery
Asthma
Cystic Fibrosis
Pneumonia
Pleurisy
Other Chest conditions
None
If you have ticked any chest conditions please give details:
If you selected none, please insert N/A in the box above
Other:
Liver Disease
Acid Reflux or eating disorder
Epilepsy
Artificial Joint
Fainting Attacks or Blackouts
Cancer
Diabetes/Family with Diabetes
Kidney Disease
Hiatus Hernia
Bone or Joint Disease
Giddiness
Any past serious illness or infectious disease
Please give details for anything ticked above:
If you selcted none, please insert N/A in the box above
Warnings
Are you or could you be pregnant
Do you require antibiotic cover for treatment
Do you have bruising or persitant bleeding after injury, surgery, or tooth extraction?
Are you currently having treatment from a Doctor, hospital or clinic?
Is there anything else that your Dentist should know?
Do you have a problem being reclined?
Have you had steroids in the last two years?
Do you carry a warning card?
Have you ever had treatment that required you to be hospitalised?
None
If you have ticked any warnings above please give details:
If you selected none, please insert N/A in the box above
Are you currently taking any medication?
*
Yes
No
Medication
List and state doses for any prescribed medicines,tablets, ointments, injections or inhalers (inc. contraceptives and HRT) that you are taking. If you do not take any medication please enter N/A
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use any recreational drugs
*
Please Select
Yes
No
Is your diet high in sugar/ or high frequency
Do you drink a lot of fizzy or acidic drinks
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
How many units of alcohol do you consume a week
a unit of alcohol is a single measure of spirits, a glass of wine/ aperitif, or a pint of beer / lager
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