Confidential Medical and Dental History Form

Confidential Medical and Dental History Form
The aim of this form is to assist your dentist in providing you with safe and optimal care.
Title
Name

First NameLast Name
Date of Birth

DayMonthYear
Address
Post code
Tel No. (home)
Tel No. (mobile)
Email
example@example.com
Occupation
NHS Number
If known

GP Details
Doctor
Surgery*
Surgery Address:-*
Have you been treated by your family doctor or a medical specialist for any illnesses in the past year? *
Please provide details :-
Are you currently under medical treatment? *
Please provide details :-
Have you ever been told by your doctor that you need to take antibiotics before dental procedures to protect your heart? *
Please provide details :-
Do you carry a Medic Alert card or bracelet or similar identifier of a medical condition? *
Please provide details :-
Are you pregnant? *
Please provide details :-
Do you have any physical or mental disability that may impair your ability to understand or consent to care? *
Please provide details :-

Do you have or have you ever had any of the following?
Rheumatic fever / congenital heart defect /bacterial endocarditis *
Please provide details :-
Heart problems / angina / arrhythmia / heartattack / heart valve problems / history of cardiac surgery *
Please provide details :-
Circulatory problems / high blood pressure /stroke / transient ischaemic attack *
Please provide details :-
High cholesterol (LDL) / triglycerides /familial hypercholesterolaemia *
Please provide details :-
Chest trouble / breathing difficulty / asthma /emphysema / bronchitis / pneumonia *
Please provide details :-
A history of bleeding problems or blood disorders in the family e.g. haemophilia or do you bruise easily or abnormally? *
Please provide details :-
Diabetes controlled by insulin (Type I) or oralmedication (Type II) *
Please provide details :-
Allergies to any of the following (please tick all that apply):*

I have no known allergiesDrugs or medicines such as penicillinLocal anaestheticsGeneral anaestheticsContact allergy e.g latex, metals, chemicalsFood allergy or intoleranceOther
Please provide details :-
Fainting attacks / giddiness / epilepsy / fits / memory loss *
Please provide details :-
Stomach or bowel disease / gastric or duodenal ulcer / hiatus hernia / acid reflux or regurgitation / IBS / coeliac disease *
Please provide details :-
Renal (kidney) disease / need for dialysis *
Please provide details :-
Liver or gall bladder disease including hepatitis / cirrhosis / jaundice / gallstones *
Please provide details :-
A transplanted organ or immuno suppressive drugs *
Please provide details :-
Endocrine / thyroid / parathyroid / pituitary /adrenal gland disease or hormonal imbalance *
Please provide details :-
Skin problems / Eczema / herpes simplex (coldsores) / psoriasis / acne / abnormal or delayed healing / keloidformation *
Please provide details :-
Bone or joint disorders / fractures /osteoporosis / arthritis / Paget’s disease / ankylosing spondylitis / vitamin D deficiency *
Please provide details :-
Headaches / migraines / jaw pain / photophobia /neck pains *
Please provide details :-
Psychiatric disorders or neurological disorders requiring medication including atypical facial pain or trigeminal neuralgia *
Please provide details :-
Eating disorder / anorexia / bulimia / history of vomiting *
Please provide details :-
Malignant disease (cancer) that requiredsurgery, chemotherapy and / or radiotherapy *
Please provide details :-
Are you a current smoker or do you currently use other tobacco products? *
Please provide details of how much and for how long you have smoked. Please include use of all tobacco or cannabis products
Have you been a smoker within the last 10 years but given up? *
If yes, how much did you smoke and for how long? :-
How many units of alcohol do you drink per week?
Pint Low strength beer - 2 units | Can of beer - 2 units | Standard (175ml) wine - 2.1 units | Shot spirits (25ml) - 1 unit l
Eye problems / glaucoma / loss of vision /cataracts / contact lenses / previous eye surgery *
Please provide details :-
Autoimmune disease / rheumatoid arthritis /lupus / multiple sclerosis / fibromyalgia / Guillain-Barre / myaesthenia gravis *
Please provide details :-
Breathing problems during sleep / sleep apnoea /snoring / periodic wakening / tiredness on waking *
Please provide details :-
Any artificial prostheses (such as a heartvalve, pacemaker, implantable defibrillator or joint replacements) *
Please provide details :-
Are you a carrier of any of the followingblood-borne viruses: HIV, Hepatitis B, Hepatitis C? *
Please provide details :-
Have you recently been abroad to a country onthe UK government's HCID (High Consequence Infectious Disease) list? *
More information can be found at HCID https://www.gov.uk/guidance/high-consequence-infectious-diseases-hcid
Please provide details :-

Medications

Please provide details of any medications you take:-
Do you take or have you ever taken the following medications? Steroid medication including tablets, creams or ointments? *
Please provide details :-
Antiplatelet or anticoagulant (blood thinning)medication *
Please provide details :-
Bisphosphonates (eg Fosamax / Actonel) orDenosumab (Xgeva or Prolia) for osteoporosis or bone disease in the last 10years? *
Please provide details :-
Please list all the medicines or drugs (prescribed, over the counter or self medication) you take on a regular basis (including contraceptive pills, homeopathic and herbal remedies, ointments, recreational drugs). Please include dosages and frequency.
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
Medication Name
Dosage
mg/ ml etc
Number of times a day
Just a number please
Taken since

DayMonthYear
Date
If you take any more medications, please complete the details in the box below:-
Please add anything else you feel may be of medical importance

Dental Information
Do you have any dental pain?*
Please provide details :-
Are there any dental problems that concern you now? *
Please provide details :-
How often do you brush your teeth? *
(times daily)
How often do you floss your teeth?*
(times weekly)
Are your teeth sensitive to hot and/or cold?*
Please provide details :-
Do your gums bleed? *
Please provide details :-
Please add anything else you feel may be of dental importance *

Signature
I hereby apply to become a patient of Mere Dentistry. I undertake to settle all fees when due either at the time of treatment or in advance. If treatment is to be paid by a third party i.e. under insurance, I remain liable for those fees until the account is settled.
Relationship to patient*
Signature *

Clear
(use mouse/ finger to draw signature)
Date

DayMonthYear
Should be Empty:

Confidential Medical and Dental History Form

COVID-19 risk assessment

IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS, WE WOULD STRONGLY ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH.

GP Details

Do you have or have you ever had any of the following?

Medications

Dental Information

Signature