Confidential Medical History Form

Confidential Medical History Form

Please Note: Unfortunately, our practice does not have disabled access. If you require disabled access, we kindly advise you to register with a practice that can better accommodate your needs. we are truly sorry for any inconvenience caused.

Title*

Forename*

Surname*

Email*

Phone Number*

Date Of Birth*

Gender*

Postcode*

Address*

Occupation*

NHS Number*

Name and Address of Doctor's Surgery

If the practice needs to contact you, are you happy for us to leave a message?

Certain medical conditions affect dental treatment and vice versa. It is very important that this form is completed fully and accurately

Have You Ever Suffered From...
Rheumatic Fever?

If yes, please provide details

Any heart complaint including a heart murmur?

If yes, please provide details

Diabetes?

If yes, please provide details

Epilepsy?

If yes, please provide details

Chronic Bronchitis or Asthma?

If yes, please provide details

Hepatitis?

If yes, please provide details

Excessive bleeding?

If yes, please provide details

High blood pressure?

If yes, please provide details

Any other serious illness?

If yes, please provide details

Please select yes or no to the following...
Do you suffer from any allergies including to medicine, tablets or substances e g. latex, food?

If yes, please provide details

Are you taking any medicine or tablets?

If yes, please provide details

Are you pregnant?

If so please give the baby's due date

Are you the mother of a child under one year of age?

If yes, please provide details

Do you smoke?

If so, how many per day?

Do you drink alcohol?

If so, how many units per day?

Do you ever suffer from cold sores?

If yes, please provide details

Did you receive growth hormone treatment before the mid-1980's?

If yes, please provide details

In the last two years have you...
Undergone an operation?

If yes, please provide details

Been treated with steroids, hydrocortisone, or corticosteroids?

If yes, please provide details

Had a joint replacement?

If yes, please provide details

Or a relative suffered from CJD?

If yes, please provide details

Received brain surgery?

If yes, please provide details

If you are aware that you have any infectious condition/disease including hepatitis or H.I.V. It is imperative you inform the dentist before treatment

Please select yes or no to the following...
Do you have any infectious diseases?

If so, please give details

Please make sure that you inform your dentist of any changes to your medical history

Patient's Signature

Date

If you are signing for the patient please give details below:

Your Name

Relationship to patient