Complete your medical history

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? emailphone/text message
Occupation/Employer *
Doctor's name & address
How did you hear of the practice?

Present Medical Status:

 
Are you fit & well?
yesno
Further Details?
Are you attending a medical practitioner on a regular basis for any medical condition?
yesno
Further Details?
Are you taking any medicines, tablets or the pill, including any inhalers?
yesno
Further Details?
Have you any allergies eg: penicillin?
yesno
Further Details?
Do you suffer from blackouts?
yesno
Further Details?
(Female patients only) Are you pregnant?
yesno
Further Details?
Do you smoke?
yesno
Further Details?

Past Medical/Dental History:

 
Have you been hospitalised or received prolonged medical treatment in the past, including the taking of steroids?
yesno
Further Details?
Have you any history of heart or chest problems including-rheumatic fever, murmurs or asthma?
yesno
Further Details?
Have you ever had a problem with excessive bleeding?
yesno
Further Details?
When did you last receive dental treatment?
yesno
Further Details?
Have you ever had any unusual reaction during or after dental treatment?
yesno
Further Details?
Are there any other details which your dentist may need to know?
yesno
Further Details?
Form completed by (Parent/Guardian)?
Opt In to receive our email newsletter?
yesno
 

Get in Touch

If you require help in these fields, please get in touch with one of our Team.

Contact Us Button