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Personal Information

Patient Details

Title*

First name*

Surname*

Email address*

Phone number*

Gender*

Date of birth*

Address*

Postcode*

Additional Information

Reminder preference*

Occupation*

Doctor's name and address*

Interests*

When did you last recieve dental treatment?*

How did you hear of us?*

If referral, by whom?

Any family members seen at the practice?*

Reason for attending?*

Emergency contact details*

Confidential Medial History

To provide the best and safest treatment, your dentist needs to know of any medical problems which may affect your treatment.

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?

Are you taking any medicines, drugs, tablets, or injections or using any creams, ointments or inhalers?

Are you taking/have taken steroids in the last 2 years?

Are you allergic to penicillin?

Are you allergic to any medicines, foods or materials?

Are you pregnant or a nursing mother?

Are you HIV positive?

Have you had Rheumatic Fever or Chorea?

Have you had jaundice, liver or kidney disease or hepatitis?

Do you have a heart murmur, heart problem, angina or high blood pressure?

Have you ever had your blood refused by the Blood Transfusion Service?

Have you ever had a bad reaction to a local or general anaesthetic?

Have you had a joint replacement or implant?

Have you been hospitalised for any reason?

Do you have arthritis?

Do you have a pacemaker/have you had heart surgery?

Do you suffer from bronchitis, asthma or other chest condition?

Do you suffer from hay fever, eczema or any other allergy?

Do you have fainting attacks, giddiness, blackouts or epilepsy?

Do you or anyone in you family have diabetes?

Do you bruise easily or suffer persistent bleeding following a tooth extraction or injury?

Do you carry a warning card?

Are you/have you ever been a smoker?

On average how many units of alcohol do you drink in a week?

Are there any other aspects, concerning your health, that your dentist should know about?

Personal Information

Patient Details

Additional Information

Confidential Medial History

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