CONFIDENTIAL MEDICAL HISTORY
PERSONAL DETAILS
Title
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
FEMALE
MALE
Home Phone Number
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Email
example@example.com
Occupation
EMERGENCY CONTACT DETAILS
Name
First Name
Last Name
RELATIONSHIP TO YOU
PHONE NUMBER
-
Area Code
Phone Number
DOCTOR'S DETAILS
DOCTORS NAME
First Name
Last Name
DOCTORS PHONE NUMBER
-
Area Code
Phone Number
DOCTORS ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ARE YOU CURRENTLY
RECEIVING TREATMENT FROM A DOCTOR, HOSPITAL OR CLINIC?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
TAKING ANY PRESCRIBED MEDICINES (EG TABLETS, OINTMENTS, INJECTIONS OR INHALERS, INCLUDING CONTRACEPTIVES AND HORMONE REPLACEMENT THERAPY)?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
CARRYING A MEDICAL WARNING CARD?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
PREGNANT OR POSSIBLY PREGNANT?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
CLINICAL INDICATIONS
HAVE YOU EVER SUFFERED FROM
ALLERGIES TO MEDICINES (EG PENICILLIN), SUBSTANCES (EG LATEX/RUBBER) OR FOODS?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
BRONCHITIS, ASTHMA OR OTHER CHEST CONDITION?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
FAINTING ATTACKS, GIDDINESS, BLACKOUTS, EPILEPSY?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
HEART PROBLEMS, ANGINA, BLOOD PRESSURE PROBLEMS, OR STROKE?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
DIABETES (OR DOES ANYONE IN YOUR FAMILY)?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
BONE OR JOINT DISEASE?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
BRUISING OR PERSISTENT BLEEDING FOLLOWING INJURY, TOOTH EXTRACTION OR SURGERY?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
LIVER DISEASE (EG JAUNDICE, HEPATITIS) OR KIDNEY DISEASE?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
ANY OTHER SERIOUS ILLNESS OR INFECTIOUS DISEASE?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
HAVE YOU EVER HAD BLOOD REFUSED BY THE BLOOD TRANSFUSION SERVICE?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
A BAD REACTION TO GENERAL OR LOCAL ANAESTHETIC?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
TREATMENT THAT REQUIRED YOU TO BE IN HOSPITAL?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
HEART SURGERY?
YES
NO
IF YES, PLEASE GIVE DETAILS BELOW:
ALCOHOL
HOW MANY UNITS OF ALCOHOL DO YOU DRINK PER WEEK? (A UNIT IS HALF A PINT, A SINGLE MEASURE OF SPIRITS OR A SINGLE GLASS):
SMOKING
DO YOU SMOKE ANY TOBACCO PRODUCTS NOW (OR DID IN THE PAST)
YES
NO
IN THE PAST
IF YES, HOW MANY CIGARETTES DO/DID YOU SMOKE PER DAY?
ADDITIONAL DETAILS
PLEASE GIVE ANY OTHER OTHER DETAILS WHICH YOUR DENTIST MIGHT NEED TO KNOW ABOUT, SUCH AS SELF-PRESCRIBED MEDICINES (EG ASPIRIN) OR ANY PHYSICAL, MENTAL OR SOCIAL CONCERNS YOU MAY HAVE.
NAME AND ADDRESS OF GENERAL DENTIST
NHS PATIENTS NUMBER
MEDICAL HISTORY UPDATE (PLEASE CHECK THAT THE HEALTH INFORMATION ON THIS FORM IS STILL CORRECT INCLUDING INFORMATION ON SMOKING AND DRINKING. IF NOT, AMEND AS NECESSARY OR NOTE ANY CHANGES).
ETHNICITY (PLEASE SELECT ONE)
01 WHITE BRITSH
02 WHITE IRISH
03 WHITE OTHER
04 WHITE & BLACK CARIBBEAN
05 WHITE & BLACK AFRICAN
06 WHITE & ASIAN
07 OTHER MIXED
08 ASIAN & ASIAN BRITISH INDIAN
09 ASIAN & ASIAN BRITISH PAKISTANI
10 ASIAN & ASIAN BRITISH BANGLADESHI
11 OTHER ASIAN BACKGROUND
12 BLACK OR BLACK CARIBBEAN
13 BLACK OR BLACK AFRICAN
14 OTHER BLACK BACKGROUND
15 CHINESE
16 OTHER ETHNIC GROUP
99 PATIENT DECLINED
COMPLETED BY
Self
Parent
Guardian
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PATIENT, PARENT OR GUARDIAN DIGITAL SIGNATURE (ACCEPTANCE OF T&C'S)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DENTIST DIGITAL SIGNATURE (ACCEPTANCE OF T&C'S)
Submit
Should be Empty: