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ALBION DENTAL 7 Albion Street, Lewes, East Sussex, BN7 2ND 01273 474 749, www.albion-dental.com Confidential Medical History Form To help us treat you safely we ask all patients the following questions about their general health. Please answer all questions with a `yes` or `no` and if necessary add any additional details. All information provided will be kept strictly confidential. Mr/ Mrs/ Miss/Ms/ Master Please Circle Surname: __________________________________________________________________________________ Forenames:_________________________________________________________________________________ Date of birth: _______________________________________________________ Male / Female (please circle) Permanent Address: _________________________________________________________________________ _____________________________________________________Post code: ____________________________ Home Telephone: ____________________________ Work Telephone: _________________________________ Mobile phone: _______________________________ E-Mail address: __________________________________ How do you prefer to be contacted?: _____________ Occupation: _____________________________________ Date of last dental treatment (if known, your previous dental practice): __________________________________ __________________________________________________________________________________________ Doctors name and address (GP): _______________________________________________________________ Doctors telephone: ___________________________________________________________________________ How did you hear about our dental practice?: ______________________________________________________ Are you currently: Pregnant? Receiving treatment from a doctor/hospital/clinic? Taking prescribed medicines (eg-tablets, ointments, injections or inhalers ,including contraceptives/ hormone replacement therapy)? Carrying a medical warning card? Taking or taken steroids in the last 2 years? YES NO IF YES, GIVE DETAILS Do you suffer from: Allergies to any medicines (eg: penicillin), substances (eg: latex Rubber), any foods. Hay fever or eczema? Bronchitis, asthma or other chest conditions? Fainting attacks, giddiness, blackouts, epilepsy? Heart problems, angina and stroke? Diabetes (or anyone in the family)? Arthritis? Bruising or persistent bleeding following injury, tooth extraction or surgery? Snoring (or anyone in your family)? Headaches/Migraines Anaemia Blood disorders: High blood pressure/Low blood pressure YES NO IF YES, GIVE DETAILS Please turn over: Did you as a child or ever since have: Rheumatic fever or chorea? Liver disease/Jaundice/Hepatitis or kidney infection Any other serious illness Blood refused by the blood service? A bad reaction towards general or local anaesthetic? A joint replacement or any other implant? Heart surgery? Brain surgery? Growth hormone treatment before the mid 1980`s? A close relative (parents, child, grandparent, Grandchildren) with Creutzfeldt-Jakob disease? Blood borne diseases i.e. Aids, HIV? YES NO IF YES, GIVE DETAILS Drinking habits: How many units of alcohol to you drink per week?_______________________units per week (1 unit= ½ pint of lager; Single measure of spirits; Single glass of wine) Smoking/chewing habits: Do you smoke any tobacco products now or in the past?____________________________________________ Do you chew tobacco, pan, sutkha or supari or have you in the past?__________________________________ PLEASE give any other details which your dentist might need to know about, such as self prescribed medicines (eg aspirin) Completed by: self…………………… parent……………………… guardian………………………… Signature:…………………………………………………………………….......................... Date: …………………….