Medical History Form
Please provide us with information about your personal details and general health to helpus treat you safely. Do not answer any questions you do not understand. You will have the opportunity to discuss any queries with your dentist who will be happy to answer any of your questions. All information will be kept strictly confidential by the people caring for you.
Confidential
Dental Comfort
Title: (Mr/Mrs/Ms/Miss)
Patient Details (Block Capitals)
First Name
Last Name
Email Address
example@example.com
Address:
Date of birth: (dd/mm/yyyy)
*
What is your gender?
Please Select
Male
Female
N/A
Telephone Number
-
Area Code
Phone Number
NHS Number:
Occupation:
By Completing this section you consent to the practice contacting your next of kin in the event of an emergency
Next of Kin: (Block Capitals) Title: (Mr/Mrs/Ms/Miss)
Contact Number
Name
First Name
Last Name
Relationship to you:
Contact Address:
When did you last visit a dentist?
Doctor's Name and Address:
Doctor's Telephone:
Please check that the health information on this form is still correct. Please note any changes to your smoking, alcohol or medicine intake and list them in the notes field provided.
Are you currently pregnant ?
Yes
No
Are you currently receiving treatment from a doctor, hospital, clinic ?
Yes
No
Are you currently taking any prescribed medicines (e.g. tablets, ointments, injections, or inhalers, eyedrops, suppositories, nebulisers, the contraceptive pill or HRT)?
Yes
No
Are you currently carrying a medical warning card ?
Yes
No
Details:
Do you suffer from any of the following ?
Allergies to any medicines (e.g. penicillin), substances (e.g. latex/rubber or foods)?
Yes
No
Hay fever or eczema?
Yes
No
Bronchitis, asthma or other chest condition?
Yes
No
Fainting attacks, giddiness, blackouts, epilepsy?
Yes
No
Muscle problems (e.g. myopathy, dystrophy, paralysis)?
Yes
No
Heart problems (e.g. angina, blood pressure problems or stroke)?
Yes
No
Diabetes (or does anyone in your family)?
Yes
No
Neurological (nerve) diseases (e.g. ‘neuropathies’, MS etc.)?
Yes
No
Arthritis?
Yes
No
Bruising or persistent bleeding following injury, tooth extraction or surgery?
Yes
No
Any infectious diseases (including HIV, hepatitis, TB)?
Yes
No
Stomach ulcers/hiatus hernia/indigestion?
Yes
No
Details:
Did you, as a child or since, have:
Rheumatic fever, heart murmur or chorea?
Liver disease (e.g. jaundice, hepatitis)?
Kidney disease?
Any other serious illness?
Details:
Did you, as a child or since, have:
Blood refused by the Blood Transfusion Service?
A bad reaction to general or local anaesthetic?
A joint replacement or other implant?
Treatment that required you to be in hospital?
Heart surgery?
Brain surgery?
Growth hormone treatment before the mid 1980s?
A close relative (parent, sibling, child, grandparent or grandchild)with Creutzfeldt Jakob Disease (CJD)?
Steroid treatment?
Details:
How many units of alcohol do you drink per week ?
Units per week (A unit is half a pint of lager, a single measure of spirits or a single glass of wine/aperitif)
Smoking and Chewing
Do you smoke any tobacco products now (or did you in the past)?
Yes
No
In the past
If yes, how many time per day do you smoke ?
Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?
Yes
No
In the past
If yes, how many time per day do chew any of the above ?
Please give any other details which your dentist might need to know about,such as self-prescribed medicines (e.g. aspirin).
Completed By:
Self
Parent
Guardian
Dentist
Signature:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dentist Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: