Medical History Form

Patient
Title Choose an item.

Forename Click or tap here to enter text.

Last Name Click or tap here to enter text.
Address Click or tap here to enter text.
Contact Telephone Number Click or tap here to enter text.
Email Address Click or tap here to enter text.
Date of Birth Click or tap here to enter text.
Occupation Click or tap here to enter text.
Gender Click or tap here to enter text.
Next of Kin
Title Choose an item.

Forename Click or tap here to enter text.

Last Name Click or tap here to enter text.
Relationship Click or tap here to enter text.
Address Click or tap here to enter text.
Contact Telephone Number Click or tap here to enter text.
Email Address Click or tap here to enter text.
GP Details
GP Name Click or tap here to enter text.
Address Click or tap here to enter text.
Telephone Number Click or tap here to enter text.
Medical Questionnaire
Are you currently or do you suffer from
Pregnant Choose an item.

Taking prescribed medicines Choose an item.

Carrying a medical card Choose an item.

Allergies to any medicines/food/contact Choose an item.

Hay fever or eczema Choose an item.

Bronchitis, asthma or chest infections Choose an item.

Fainting attacks Choose an item.

Muscle problems Choose an item.

Heart problems Choose an item.

Diabetes Choose an item.

Neurological diseases Choose an item.

Arthritis Choose an item.

Bruising after tooth extraction or surgery Choose an item.

Any infectious diseases Choose an item.

Stomach ulcers Choose an item.

Liver disease Choose an item.

1|Page
 Kidney disease Choose an item.

Did you as a child or since have

Blood refused by Blood Transfusion Service? Choose an item.

Bad reaction to anaesthetic Choose an item.

Joint replacement or implant Choose an item.

Been hospitalised Choose an item.

Heart surgery Choose an item.

Brain surgery Choose an item.

Growth hormone treatment Choose an item.

Family with Creutzfeldt Jakob Disease Choose an item.

Steroid disease Choose an item.

Drinking
Units of alcohol do you drink per week Click or tap here to enter text.
Smoking
Do you smoke or chew tobacco products Choose an item.

Please provide any other relevant information which we should know about
Click or tap here to enter text.

Form completed by Choose an item.

Declaration
Patient Signature Click or tap here to enter text.
Dentist Signature Click or tap here to enter text.

2|Page