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  • 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) :*
  • Today's Date:*
     / /
  • Sex*
  • Date of birth:*
     / /

  • In the event of an emergency, please contact

  • Doctor’s details

  • Are you currently :

  • Receiving treatment from a doctor, hospital or clinic?*
  • Taking any prescribed medicines (e.g. tablets, ointments, injections or inhalers, including contraceptives & hormone replacement therapy?*
  • Carrying a medical warning card?*
  • Pregnant or possibly pregnant?*

  • Have you ever had :

  • Allergies to medicines (e.g penicillin), substances (e.g latex/rubber) or foods?*
  • Bronchitis, asthma or any other chest condition?*
  • Fainting attacks, giddiness, blackouts, epilepsy?*
  • Heart problems, angina, blood pressure problems or stroke?*
  • Diabetes (or does anyone in your family?)*
  • Bone or joint disease?*
  • Bruising or persistent bleeding following injury tooth extraction or surgery?*
  • Liver disease (e.g jaundice, hepatitis), kidney disease or thymus disorder?*
  • Any other serious illness or infectious disease?*

  • Have you ever had :

  • Blood refused by the Blood Transfusion Service?*
  • A bad reaction to general or local anaesthetic?*
  • Treatment that required you to be in hospital?*
  • Heart surgery/spleen or thymus gland removed?*

  • Alcohol :

  • Smoking :

  • Do you smoke any tobacco products now (or did you in the past)?
  • Do you vape?*
  • Do you chew tobacco, panuse gutkha or supari now(or did you in the past?
  • Are you happy to receive our clinic newsletter with advice, tips and special offers and promotions via email/text*
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  • Should be Empty: