NEW Medical History Form

Medical History Form

Shiraz Endodontic Practice
389 Warwick Road, Solihull, B91 1BJ
info@shirazendo.com
0121 709 1660
Like all dentists, we ask patients for information about their general health to help us treat them safely. Please complete this form, which the dentist will discuss fully with you before commencing treatment. If you have any questions, please ask the dentist. All information will be kept completely confidential.
Patient Information
Patient Name

Patient TitlePatient First NamePatient Last Name
Patient Contact Number
Patient Email Address
Patient Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Occupation

Data Privacy & Consent Agreement
Data Protection (GDPR) - I consent for my information to be shared in accordance with the practice's GDPR policy, if necessary, with consent
Completed by:
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

Rows	Yes	No	Give details
Do you attend the dentist regularly? Please give details of how often.
Do you brush your teeth twice a day?
Do you use an electric toothbrush?
Do you clean between your teeth daily? (e.g. floss, interdental brushes). Please give details.
Do you suffer with anxiety when going to the dentist? Please give details.
Do you clench or grind your teeth? Please give details.
Do you have a high sugar diet? (e.g cakes, biscuits, sugar in tea/coffee etc?)
Do you have a high acid diet? (e.g. cider, fizzy drinks, sour sweets etc?)
Do you use a toothpaste with fluoride? Please give details
Have you had braces in the past? Please give details
Have you had any dental trauma in the past? Please give details

Rows	Yes	No	Give details
Receiving treatment from a Doctor, Hospital, or Clinic? Carry a warning card?
Taking any prescribed medicines (tablets, ointments, injections, inhalers)?
Allergic to any medicines, foods, or materials, in particular to penicillin or rubber (latex)?
Pregnant?
Smoke cigarettes/vape, or used to? (if so, how many per day?)
Drink alcohol? (if so, how many units per week?)
Are you currently stressed? If yes, please state low, medium or high

Rows	Yes	No	Give details
Hay fever?
Cold sores?
Eczema?
Arthritis?
Bronchitis, asthma or other chest conditions?
Fainting attacks, giddiness, blackouts or Epilepsy?
Heart problems, angina, blood pressure problems or stroke?
Have a pacemaker, or have you had any form of heart surgery?
Diabetes (or does anyone in your family)?
Bruising or persistent bleeding following injury, tooth extraction, or surgery?
Any infection diseases (including HIV and hepatitis)?

Rows	Yes	No	Give details
Rheumatic fever or chorea?
Liver disease (jaundice, hepatitis) or kidney disease or any other serious illness?
Blood refused by the blood transfusion service?
A bad reaction to general or local anaesthetic?
Joint replacement or other implants?
A close relative with Creutzfeldt Jakob Disease (CJD)?
Have you or a close relative shown any signs/symptoms of Covid-19 in the last 14 days?

Patient Information