Medical History Form

Medical History Form

Please, fill out your medical information carefully. For the best user experience, please use a desktop computer, laptop, or tablet when answering the questions below.

It is very important for our Clinic and personel to understand your medical needs before any examination or treatment is carried out. Any information given to us is strictly confidential.
Your Title*

Mr.Ms.Mrs.Miss.
Your Name*

As per IDAs per ID
Customer ID:*
You can find your customer ID in all communication emails with us.
Your Date of Birth:*
Date - Month - Year
Your Address:*

Street and Number

Street Address Line 2

City / TownState / County

PostcodeCountry
Phone Number (daytime):*
Phone number (mobile):
Email:*
Occupation:*
Do you have mobility problems?*

YesNo
Are you pregnant?*

YesNo
How did you first hear about Dentaprime UK Dental Clinic?*

Medical History

Please answer the questions below concerning your health condition as precise as possible. Your answers will remain confidential in accordance with the Data Protection Act.
Last GP visit:*
Last dental visit*
Last hygiene visit*
Are you taking or have you taken steroids in the last 2 years?*

YesNo
If yes, when*
If yes, for what period*
If yes, please specify the reason*
Have you had a prolonged illness?*

YesNo
If yes, when*
If yes, please specify the reason*
If yes, please specify the outcome*
Have you been hospitalized or had any major/serious operation?*

YesNo
If yes, when*
If yes, please specify the reason*