The family dentist with in house specialist team

Confidential Medical History Form

In order for us to treat you safely we require some information about you and your general health. Please answer all of the questions on this form as accurately as possible. We will follow this up at regular intervals in future so that you can keep us updated about any changes in your general health. All information will be kept strictly confidential.

Alternatively, you can print out this form by clicking on this link. You can fill in the printed copy and bring it with you when you next visit the surgery.

Title
Surname
Forenames
Gender
Date of birth
Address
Home telephone
Work telephone
Email address
Occupation
Date of last dental treatment
Doctor's name and address
Doctor's telephone
Are you pregnant?	Yes No
Are you receiving treatment of any kind from a doctor, hospital or clinic?	Yes No
Are you taking any prescribed medicines (eg tablets, ointments, injections or inhalers, including contraceptives or hormone replacement therapy)?	Yes No
Are you carrying a warning card?	Yes No
Do you suffer from allergies to any medicines (eg. Antibiotics) substancess (eg. Latex/rubber) or foods?	Yes No
Do you suffer from hay fever or eczema?	Yes No
Do you suffer from bronchitis, asthma or other chest condition?	Yes No
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?	Yes No
Do you suffer from heart problems, angina, blood pressure problems, or stroke?	Yes No
Do you suffer from diabetes or does anyone in your family?	Yes No
Do you suffer from arthritis?	Yes No
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?	Yes No
Do you suffer from any infectious diseases (including HIV or hepatitis)?	Yes No
Have you had rheumatic fever or chorea (St Vitus Dance)? Liver disease (eg jaundice, hepatitis or kidney disease)?	Yes No
Have you had any other serious illness?	Yes No
Have you had blood refused by the Blood Transfusion Service?	Yes No
Have you had a bad reaction to general or local anaesthetic?	Yes No
Have you had a joint replacement or other implant?	Yes No
Have you had treatment that required you to be in hospital?	Yes No
Have you had heart surgery?	Yes No
Have you had brain surgery?	Yes No
Have you travelled to the Far East recently?	Yes No
Have you had growth hormone treatment before the mid 1980s?	Yes No
Have you a close relative with Creutzfeldt Jakob Disease?	Yes No
How many units of alcohol do you drink per week?
Do you smoke any tobacco products now or did you in the past?	Yes No
Do you chew tobacco, pan or supari now or did you in the past?	Yes No
Are there any other details about which we may need to know, such as self-prescribed medicines?	Yes No
Please tell us about any medication you are currently taking?

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