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Confidental medical history form

So we can treat you safely, we need certain information about you and your general health. Please answer all the questions on this form as accurately as you can. When we see you, we may ask you for further details about any questions you have answered 'yes' to.

woman in a wheelchair in a field

We'll also follow up these issues at regular intervals so we're always updated about any changes in your general health. Of course, we'll keep all your information strictly confidential.

Please fill out the form online and press submit when you have finished.

Alternatively, to print this form, click on this link and print out the PDF version of the form. Then fill it in, and either bring it when you come for your next appointment, or send it to our postal address: Granta Dental, The Old Coach House, 53 Newnham Road, Cambridge, CB3 9EY.

Identity information

Title

Forenames

Surname

Gender

Date of birth

Contact information

Address

Postcode

Daytime telephone number

Evening telephone number

Mobile telephone number

Email address

How do you want us to contact you?

Occupation

GP's name

GP's address

GP's telephone number

Date of last dental treatment

Medical information

Are you pregnant?

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

Do you chew tobacco, pan or supari now, or did you in the past?

How many units of alcohol do you drink per week?

01-14
14-28
More than 28

Are you using any prescribed medicines (eg. tablets, ointments, injections or inhalers, including contraceptives or hormone replacement therapy)?

Are you using any self-prescribed medications?

Are you receiving treatment of any kind from a doctor, hospital or clinic?

Are you carrying a warning card?

Do you suffer from allergies to any medicines (eg. antibiotics), substances (eg. latex/rubber), or foods (eg. chocolate)?

Do you suffer from hay fever or eczema?

Do you suffer from bronchitis, asthma or other chest condition?

Do you suffer from heart problems, angina, blood pressure problems or stroke?

Do you suffer from diabetes or does anyone in your family?

Do you suffer from arthritis?

Do you typically suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?

Do you suffer from any infectious diseases (including HIV or hepatitis)?

Have you had rheumatic fever or chorea (St Vitus Dance)? Liver disease or kidney disease (eg jaundice, hepatitis)?

Have you had a joint replacement or other implant?

Have you had blood refused by the Blood Transfusion Service?

Have you had a bad reaction to general or local anaesthetic?

Have you had heart surgery

Have you had brain surgery?

Have you travelled to the Far East recently?

Have you had growth hormone treatment before the mid 1980s?

Have you a close relative with Creutzfeldt Jakob Disease?

Have you had other treatment that required you to be in hospital?

Have you had any other serious illness we have not asked about?

Are there any other details about which we may need to know?

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Granta Dental

The Old Coach House

53 Newnham Road

Cambridge CB3 9EY

T 01223 461 381

E reception@grantadental.co.uk

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Temporomandibular joint disorder
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