Call us on: 01628 620764
Email us on: reception@orcharddental.co.uk
See us at: 1 Frascati Way, Maidenhead, Berkshire. SL64UU

We are open Monday to Thursday 9:00am - 5:30pm and Friday 9:00am - 5:00pm. In celebration of our 75th year, our Welcome Appointment fee inclusive of all required x-rays is £75.

medical history form

Please note: All fields marked with an * are required fields. These must be filled in before submitting the form.

Your details
Title:
First name*:
Last name*:
Date of birth*:
Address:
Postcode:
Home phone:
Mobile phone:
Email address*:
Referring Dentist:
Referring Dentist Tel:
GP Name:
GP Tel:
1. Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? If yes, please explain

Yes No Dont Know
2. Has there been any change in your general health within the past year? If yes, please explain

Yes No Dont Know
3. Are you under the care of a physician for a current problem? If yes, please explain

Yes No Dont Know
4. Have you been hospitalised within the past five years? If yes, please explain

Yes No Dont Know
5. Are you taking any medication or drugs? If yes, please list their full names, quantity and frequency below.

Yes No Dont Know
Have you received therapy for alcoholism or drug addiction during the past five years?

Yes No Dont Know
Have you ever had any ALLERGIC or ADVERSE REACTIONS to anaesthetics, antibiotics, medications?

Yes No Dont Know
Are you required to take antibiotics prior to dental treatment?

Yes No Dont Know
Have you had abnormal bleeding with previous extractions, surgery, or trauma?

Yes No Dont Know
Have you ever required a blood transfusion?

Yes No Dont Know
Have you ever had surgery and/or radiation for a tumour, growth or any other related condition?

Yes No Dont Know
Have you ever tested positively for HIV infection or AIDS? If so, state date diagnosed and treating doctor.

Yes No Dont Know
Is there any other condition concerning your health that the endodontist should be told?

Yes No Dont Know
Are you taking any herbal medicine (ie, St John’s Wort)?

Yes No Dont Know
Do you smoke? If yes, please state how many per day?

Yes No Per day

Do you have or have you had any of the following?

High Blood Pressure
Heart murmur or prolapsed valve
Joint Prosthesis (Hip, Knee etc)
Rheumatic fever or rheumatic heart disease
Congenital heart disease
Cardiovascular disease: heart attack, stroke or bypass
Prosthetic heart valve
Blood disorder (e.g. anaemia)
Venereal disease
Asthma
Allergy to latex
Low blood pressure
Chest pain, angina
Swollen ankles, arthritis or joint disease
Cardiac pacemaker
Heart surgery
Delay in healing
Tuberculosis
Emphysema
X-Ray treatment or chemotherapy
On a diet
History of alcohol abuse
Eye disease or glaucoma
Infectious mononucleosis

Sinus trouble
Thyroid problems
Diabetes
Stomach ulcers, colitis
Hepatitis, jaundice, liver disease
Kidney problems
Psychiatric treatment
Fainting spells or seizures
Epilepsy
Cancer
Temporomandibular joint problems (TMJ)
Low blood sugar
Dialysis
Irregular heart beat
Contagious Diseases
Bronchitis, chronic cough
Hay fever or sinus problems
Problems with the immune system
Difficult breathing or other lung trouble
Chronic fatigue or night sweats
History of drug abuse
Wear contact lenses
Bruise easily
Gallbladder trouble

Do you have any disease, condition or problem not listed above? If yes, please specify

Yes No Dont Know

WOMEN ONLY

Possibility of pregnancy?

Yes No Est Due Date
Nursing?

Yes No
Taking birth control?

Yes No

PLEASE NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of control.

INJURY

Is this visit related to an accident

Yes No
Was it work related?

Yes No Date of
Insurance Company handling claim:
Claim number:
Todays Date:

medical history form

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