Here you can fill out your medical history, prior to treatment

Title *
Name *
DOB *
Home Address *
Email *
Home Telephone No *
Work Telephone No
Mobile Telephone No
How would you prefer to receive your dentist & hygienist recall?	email phone/text message
Occupation/Employer *
Doctor's name & address
How did you hear of the practice?
Present Medical Status:
Are you fit & well? yes no	Further Details?
Are you attending a medical practitioner on a regular basis for any medical condition? yes no	Further Details?
Are you taking any medicines, tablets or the pill, including any inhalers? yes no	Further Details?
Have you any allergies eg: penicillin? yes no	Further Details?
Do you suffer from blackouts? yes no	Further Details?
(Female patients only) Are you pregnant? yes no	Further Details?
Do you smoke? yes no	Further Details?
Past Medical/Dental History:
Have you been hospitalised or received prolonged medical treatment in the past, including the taking of steroids? yes no	Further Details?
Have you any history of heart or chest problems including-rheumatic fever, murmurs or asthma? yes no	Further Details?
Have you ever had a problem with excessive bleeding? yes no	Further Details?
When did you last receive dental treatment? yes no	Further Details?
Have you ever had any unusual reaction during or after dental treatment? yes no	Further Details?
Are there any other details which your dentist may need to know? yes no	Further Details?
Form completed by (Parent/Guardian)?

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