Medical history

Confidential Medical History Form

Please note deposits may be required for some treatments and hygiene appointments. If you fail to attend or do not give 24 hours notice for cancellation your appointment may be kept.

Welcome to Best Health Clinics! In order to help us meet all of your dental/medical health care needs, please complete the following Medical History Form.

Please ask a member of our team if you need any assistance or have any questions. We will use this form in future visits to discuss any changes to your health. All responses will be treated in strictest confidence by the team caring for you.

Please check that health information on this form is still correct (including information on smoking and drinking) if not, amend as necessary or note any changes below.

Completed by (please tick) :*

selfparentguardian

Name*

TitleFirst nameLast name

Today's Date:*

Date

Sex*

FemaleMale

Date of birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone number (home):

Mobile number:

Email

example@example.com

Occupation

In the event of an emergency, please contact

Name:*

Telephone number:*

Relationship to you:*

Doctor’s details

Doctor's name:

Telephone number:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you currently :

Receiving treatment from a doctor, hospital or clinic?*

YesNo

Give Details

Taking any prescribed medicines (e.g. tablets, ointments, injections or inhalers, including contraceptives & hormone replacement therapy?*

YesNo

Give Details

Carrying a medical warning card?*

YesNo

Give Details

Pregnant or possibly pregnant?*

YesNo

Have you ever had :

Give Details

Allergies to medicines (e.g penicillin), substances (e.g latex/rubber) or foods?*

YesNo

Give Details

Bronchitis, asthma or any other chest condition?*

YesNo

Give Details

Fainting attacks, giddiness, blackouts, epilepsy?*

YesNo

Give Details

Heart problems, angina, blood pressure problems or stroke?*

YesNo

Give Details

Diabetes (or does anyone in your family?)*

YesNo

Give Details

Bone or joint disease?*

YesNo

Give Details

Bruising or persistent bleeding following injury tooth extraction or surgery?*

YesNo

Give Details

Liver disease (e.g jaundice, hepatitis), kidney disease or thymus disorder?*

YesNo

Give Details

Any other serious illness or infectious disease?*

YesNo

Give Details

Have you ever had :

Blood refused by the Blood Transfusion Service?*

YesNo

Give Details

A bad reaction to general or local anaesthetic?*

YesNo

Give Details

Treatment that required you to be in hospital?*

YesNo

Give Details

Heart surgery/spleen or thymus gland removed?*

YesNo

Give Details

Alcohol :

How many units of alcohol do you drink per week? (A unit is half a pint of lager, a single measure of spirits or a single glass of wine/aperitif.) *

Units per week

Smoking :

Do you smoke any tobacco products now (or did you in the past)?

YesNoIn the past

Times per day :*

Do you vape?*

YesNoIn the past

Times per day:*

Do you chew tobacco, panuse gutkha or supari now(or did you in the past?

YesNoIn the past

Times per day :*

Where did you hear about us?*

Are you happy to receive our clinic newsletter with advice, tips and special offers and promotions via email/text*

YesNo

Please give any other details which your clinician might need to know about, such as self prescribed medicines (e.g. Aspirin) or any disabilities you may have.