Download Confidential medical history form

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: …………………….