Confidential Medical History Form Title* Please Select TitleMrMsMrsMissDrMxSirLordLadyDame Forename* Surname* Email* Phone Number* Date Of Birth* Gender* MaleFemale 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? YesNo 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? NoYes If yes, please provide details Any heart complaint including a heart murmur? NoYes If yes, please provide details Diabetes? NoYes If yes, please provide details Epilepsy? NoYes If yes, please provide details Chronic Bronchitis or Asthma? NoYes If yes, please provide details Hepatitis? NoYes If yes, please provide details Excessive bleeding? NoYes If yes, please provide details High blood pressure? NoYes If yes, please provide details Any other serious illness? NoYes 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? NoYes If yes, please provide details Are you taking any medicine or tablets? NoYes If yes, please provide details Are you pregnant? NoYes If so please give the baby's due date Are you the mother of a child under one year of age? NoYes If yes, please provide details Do you smoke? NoYes If so, how many per day? Do you drink alcohol? NoYes If so, how many units per day? Do you ever suffer from cold sores? NoYes If yes, please provide details Did you receive growth hormone treatment before the mid-1980's? NoYes If yes, please provide details In the last two years have you... Undergone an operation? NoYes If yes, please provide details Been treated with steroids, hydrocortisone, or corticosteroids? NoYes If yes, please provide details Had a joint replacement? NoYes If yes, please provide details Or a relative suffered from CJD? NoYes If yes, please provide details Received brain surgery? NoYes 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? NoYes 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: NoYes Your Name Relationship to patient
