Medical History Form

Patient Details

• Do You Have Private Dental Insurance: Please Choose... Yes No

• Are You Exempt For Payment Of Dental Fees?: Please Choose... Yes No

Further Information - Please Complete As Appropriate

• Are you currently pregnant? Please Choose... Yes No

• Are you currently receiving treatment from a doctor, hospital or clinic? Please Choose... Yes No

• Have you had treatment that required you to stay in hospital & has this involved surgery? Please Choose... Yes No

• Do you carry a medical warning card or bracelet? Please Choose... Yes No

• Are you currently taking any prescribed medicines (e.g. tablets, ointments or inhalers including contraceptives and hormone replacement therapy)? Please Choose... Yes No

• Do you suffer from any allergies to medicines (e.g. penicillin), substances (e.g. latex or rubber) or foods? Please Choose... Yes No

• Do you suffer from hay fever or eczema? Please Choose... Yes No

• Do you suffer from bronchitis, asthma or other chest conditions? Please Choose... Yes No

• Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? Please Choose... Yes No

• Do you suffer from heart problems, angina, blood pressure problems or stroke? Please Choose... Yes No

• Are you diabetic (or is anyone in your family?) Please Choose... Yes No

• Do you suffer from arthritis? Please Choose... Yes No

• Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? Please Choose... Yes No

• Do you suffer from any infectious disease (including HIV & hepatitis) Please Choose... Yes No

• Have you ever had rheumatic fever or chores? Please Choose... Yes No

• Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease? Please Choose... Yes No

• Have you ever had any other serious illness Please Choose... Yes No

• Have you ever had blood refused by the Blood Transfusion Service? Please Choose... Yes No

• Have you ever had a reaction to general or local anesthetic? Please Choose... Yes No

• Have you ever had a joint replacement or any other implant? Please Choose... Yes No

• Have you ever had brain surgery? Please Choose... Yes No

• Do you have any close relative (parent, sibling, child, grandparent or grandchild) with Creutzfeldt jakob disease? Please Choose... Yes No

• If you are female, do you regularly drink more than 14 units of alcohol per week? Please Choose... Yes No

• If you are male, do you regularly drink more than 21 units of alcohol per week? Please Choose... Yes No

• Do you smoke, or have you ever smoked? Please state how much and when. Please Choose... Yes No

• Do you chew tobacco, pan, gutkha or supari now (or did you in the past)? Please Choose... Yes No

• Is there any other information that your dentist might need to know about? Such as aspirin etc. Please Choose... Yes No

• Do you suffer from cold sores? Please Choose... Yes No

• Have you ever had heart surgery, or been fitter with a pace maker? Please Choose... Yes No