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Confidential Medical History
To offer the best and most appropriate dental care, please provide us with as much
detail as possible about you medical history.
How did you hear about the practice? □ Friend/Family □ Referral card □ Internet/website
If other please can you tell us………………………………………………………………………………………………………………
Title: ……………… Full name:……………………………………………………………………………………
Date of Birth:………………………………………………..
Address:………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
Postcode:…………………………………… Home No:…………………………………………………………………………………..
Mobile No:…………………………………. Work No:……………………………………………………………………………………
Email:…………………………………………………………………………………………………………………………………………………..
Occupation:…………………………………………………………………………………………………………………………………………
Name and address of your doctor:………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………….
Are you;
Circle details
Receiving treatment from your doctor or hospital?
Yes/No
Taking any medication?
Yes/No
(e.g. inhalers, oral contraceptives, hormone replacement therapy) Please list medication below;
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………..
Do you have or have ever suffered from;
Any allergies (penicillin, substances e.g. latex, or foods)?
Heart problems, heart surgery, angina, blood pressure problems or stroke?
Rheumatic fever or chorea?
Had liver disease (e.g. jaundice, hepatitis) or kidney disease?
Asthma, bronchitis or other chest infections?
Bruise or bleed excessively following injury, tooth extraction or surgery?
Ever had blood refused from the Blood Transfusion service?
Experience fainting attacks, giddiness, blackouts or epilepsy?
Ever had a bad reaction to general or local anaesthetic?
Carrying a medical warning card?
Are you diabetic (or is anyone in your family)?
Are you pregnant or breastfeeding?
Suffer from, infectious diseases (including HIV and Hepatitis)?
Any close relative (parent, sibling, child, grandparent or grandchild)
with Creautzfeldt Jakob disease (CJD)?
Arthritis?
Take any steroids or receiving any treatment for cancer (chemo/radio) or osteoporosis?
A joint replacement or other implant?
Smoke any tobacco products now (or did you in the past)?
Regularly drink more than 21units of alcohol per week?
Signed:……………………………………………………………………….
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Date:………………………………………………