Medical History Form - F3T

  • 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*
  • Do you have mobility problems?*
  • Are you pregnant?*

  • Details of contacts in case of emergency/ Next of kin

  • Title*

  • GP Contact Details

  • 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.

  • Are you taking or have you taken steroids in the last 2 years?*
  • Have you had a prolonged illness?*
  • Have you been hospitalized or had any major/serious operation?*

  • Heart/blood conditions

  • Heart operation*
  • Stroke*
  • Heart valve condition*
  • Heart attack*
  • Heart Pacemaker*
  • Heart arrhythmia*
  • Angina*

  • Infectious diseases

  • HIV / AIDS*
  • Tuberculosis*
  • Hep A*
  • Hep B*
  • Hep C*

  • Allergies

  • To local anaesthetic*
  • To pain killers*
  • To other medication*
  • To plastic (p.e. latex)*
  • To metal*

  • Other Conditions

  • Seizure disorder*
  • Rheumatic fever*
  • Hay Fever*
  • Glaucoma*
  • Epilepsy*
  • Kidney disease*
  • Osteoporosis*
  • Lupus*
  • Underactive thyroid*
  • Overactive thyroid*
  • Stomach Hernia*
  • Anxiety*
  • Depression*
  • Blood clotting disorder*
  • Arthritis*
  • COPD*
  • Asthma*
  • Fibromyalgia*
  • High blood pressure*
  • Low blood pressure*

  • Other Conditions

  • Mental disorder*
  • Diabetes*
  • What type?*
  • Do you have Cancer?*
  • Have you had radiation?*
  • Have any complications occurred during operations?*
  • Do you have the habit of grinding or clenching?*
  • Do you have pharyngeal reflex known as gag reflex?*
  • Do you have severe bleeding/bruising problem?*
  • Do you have a dental phobia?*
  • Have you got implants in your body? (incl. dental)*
  • Have you got periodontists or have you been treated for it?*
  • Have you ever had any ill affects following dental treatment?*

  • Other Conditions

  • Do you smoke?*
  • Do you drink alcohol?*
  • Have you ever been Drug-addicted*
  • If still in recovery, for how long?

  • Covid-19

  • Have you had COVID-19?*
  • Have you been vaccinated against COVID-19?*
  • Please confirm:*
  • Date today
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