Medical History form

Your details

Please provide the patients personal details
Title:-
Name:-*

First NameLast Name
Preferred name:-
Sex*

MaleFemale
Date of Birth:-*

DayMonthYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:-*

Area CodePhone Number
Mobile:-
Occupation:
Email:*
example@example.com
NHS Number:
If known

Other contact details
In the event of an emergency, please contact:-
Name:*
Telephone number:*
Relationship to you:*
Doctor's details:-
Doctor's name:
Telephone number:
Practice's address:*
Postcode:

Personal habits:-
How would you describe your consumption of alcohol?*
Please give details:-
ie units per week
Do you smoke any tobacco products now (or, did you in the past)?*

YesNoPast
Times per day
Do you chew tobacco, pan, use gutkha, supari or betel now (or, did you in the past)?*

YesNoPast
Times per day
Do you vape/ use electronic cigarettes (or, did you in the past??*

YesNoPast
Times per day

Any thing else:-
Please give any other details which your dentist might need to know about, such as self-prescribed medicines (eg aspirin) or any disabilities or health concerns you may have:-
Medical history update:-
Please provide us with any health information that has changed since your last visit, including information on smoking, drinking, medication, hospital attendance etc.

Details:-

	Date	Any Changes	List changes	Patient Initials
1:-
2:-
3:-
4:-

Authorisation:-
Completed by:-*

SelfParentGuardianOther
Patient signature*

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

DayMonthYear
Date
Should be Empty: