Patient Details
Name
*
Email
*
D.O.B
*
Telephone Number
*
Health & Care Number
Name and address of your doctor
*
Telephone number of your doctor
*
Medical History Questions
Do you suffer from?
Any heart complaints? E.g. Heart Surgery, Angina, Heart attack, Pacemaker or other?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your heart complaints
High Cholesterol?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your high cholesterol
Blood Pressure?
*
High (Please provide more information and medication)
Low (Please provide more information and medication)
No
Please provide more information and medication for your blood pressure
Chest/Breathing problems? E.g. Asthma, COPD, Bronchitis etc.
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Chest/Breathing problems
Diabetes?
*
Yes, Type 1 (Please provide more information and medication)
Yes, Type 2 (Please provide more information and medication)
No
Please provide more information and medication for your diabetes
Epilepsy, seizures or Blackouts?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Epilepsy, seizures or Blackouts
Hepatitis/liver disease?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Hepatitis/liver disease
Kidney Disease?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Kidney Disease
Excessive Bleeding or Bruising?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Excessive Bleeding or Bruising
Blood Conditions E.g. Anaemia, Haemophilia?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Blood Conditions
Mental health issues / depression / anxiety?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Mental health issues / depression / anxiety
Any other serious illness or infectious disease?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your serious illness or infectious disease
Do you have any disabilities, mobility issues or sensory problems?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your disabilities, mobility issues or sensory problems
Are you prone to fainting/fits?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your fainting/fits
Gastointestinal, stomach or digestive problems?
*
Yes (Please provide more information and medication)
No
Please provide more information and medication for your Gastointestinal, stomach or digestive problems
Have you ever had a stroke or a blood clot (thrombosis)?
*
Yes (Please provide more information)
No
Date of your stroke or a blood clot (thrombosis)
Do you...
Consume Alcohol
*
Yes (Please provide more information)
No
How many units per week?
Smoke or use an E-cigarette?
*
Yes (Please provide more information)
No
In the past
How many per day?
Are you...
Allergic to Penicillin?
*
Yes
No
Allergic to any medicines, tablets or materials? E.g. latex, rubber, plasters etc
*
Yes (Please provide more information)
No
Allergies
Has your GP advised you to avoid any medication?
*
Yes (Please provide more information)
No
Please provide more information about the advice from your GP
Taking the oral contraceptive pill?
*
Yes (Please provide more information)
No
Please provide more information about your oral contraceptive pill
Pregnant or possibly pregnant?
*
Yes (Please provide due date)
Possibly Pregnant
No
Due Date
/
Day
/
Month
Year
Date
Are you breastfeeding?
*
Yes
No
Using any other prescribed medication?
*
Yes (Please provide more information)
No
Please provide more information about any other prescribed medication
Using any self prescribed medication?
*
Yes (Please provide more information)
No
Please provide more information about any self prescribed medication
In the past two years have you?
Undergone any operations?
*
Yes (Please provide date below)
No
Date of operation
/
Day
/
Month
Year
Date
Been treated with hydrocortisone, corticosteroids or DMARDS?
*
Yes
No
Date of treatment
/
Day
/
Month
Year
Date
Have you a bone/joint disease? E.g. Osteoporosis, arthritis etc
*
Yes
No
Please provide more information about your bone/joint disease
Been treated with bisphosphonates? (bone tablets)
*
Yes (Please provide name of treatment)
No
Please provide name of bisphosphonates treatment
Have HIV or any other blood-borne viruses? E.g. Hepatitis B or C
*
Yes
No
Have you ever had a bad reaction to local/general anaesthetic?
*
Yes (Please provide more information)
No
Please provide more information about your bad reaction to local/general anaesthetic
Been diagnosed with Cancer or had it in the past?
*
Yes (Please provide more information)
No
Name of treatment? E.g Chemo, surgery, radio?
Emergency Contact Details
In case of an emergency contact the person below
Emergency Contact Name
*
Emergency Contact Telephone Number
*
Medical history completed by?
*
Self
Parent/Guardian
With a practice staff member
Signature
*
By submitting this form you are giving Carleton Dental Practice permission to securely store your details.
*
Yes, please store my medical history details securely
Submit Medical History Form
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