Tel: 0117 9238 400 Fax: 0117 9467 007 Email: info@rootfillings.com

Medical history form

If you wish to print out the medical history form and bring it with you to the practice, please click here.

Section 1.
Title:
First name:
Last name:
Home phone:
Mobile phone:
Work phone:
Fax:
Date of birth:
Occupation:
Address:
Postcode:
Email address:
Referring dentist:
Referring dentist phone:
(if known)
Family Doctor:
Family Doctor phone:
(if known)
Section 2
Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth?
- Yes:
- No:
- Don't know:
If yes, please explain:
Has there been any change in your general health within the past year?
- Yes:
- No:
- Don't know:
If yes, please explain:
Are you under the care of a physician for a current problem?
- Yes:
- No:
- Don't know:
If yes, please explain:
Have you been hospitalized within the past 5 years?
- Yes:
- No:
- Don't know:
If yes, please specify:
Are you taking any medication or drugs?
- Yes:
- No:
- Don't know:
If yes, please list their full names, quantity and frequency:
Have you received therapy for alcoholism or drug addiction during the past 5 years?
- Yes:
- No:
- Don't know:
Have you ever had any ALLERGIC or ADVERSE REACTIONS to anesthetics / antibiotics / medications?
- Yes:
- No:
- Don't know:
Are you required to take antibiotic cover prior to dental treatment?
- Yes:
- No:
- Don't know:
Have you had abnormal bleeding with previous extractions, surgery or trauma?
- Yes:
- No:
- Don't know:
Have you ever required a blood transfusion?
- Yes:
- No:
- Don't know:
Have you ever had surgery and/or radiation for a tumor, growth, or other related condition?
- Yes:
- No:
- Don't know:
Have you ever tested positively for HIV infection or AIDS?
- Yes:
- No:
- Don't know:
If so, state date diagnosed and treating doctor:
Is there any other condition concerning your health that the dentist should be told?
Section 3
Do you have or have you had any of the following? Tick for 'yes' or leave blank for 'no':
- 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. anemia):
- 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:
- 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:
- Gall bladder trouble:
- None of the above:
Section 4
Are you taking any herbal medicine (i.e., St. John's Wort)?
- Yes:
- No:
- Don't know:
Do you smoke?
- Yes:
- No:
If so, how many per day?
Do you have any disease, condition or problem not listed above?
- Yes:
- No:
If so, please specify:
Section 5: Women only
Possibility of pregnancy:
- Yes:
- No:
If so, estimated delivery date:
Nursing:
- Yes:
- No:
Taking birth control pills:
- Yes:
- No:
NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gyneacologist for assistance regarding additional methods of control.
This visit is related to an accident:
- Yes:
- No:
Work related:
- Yes:
- No:
Date of injury:
Insurance company handling the claim:
Claim number:
Confirmation
By ticking the following box you agree that the details you have entered in the fields above are as detailed and accurate as possible.:
- I agree:

Medical history form

Section 1.

Section 2

Section 3

Section 4

Section 5: Women only

Confirmation