Please print and complete this form. Please bring the completed form along to your dental appointment.
Patient Medical History
| Title | Surname | First Names |
| Mr/ Mrs/Miss |
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| Address | Telephone Numbers
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Postcode -
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Date of Birth
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Occupation | Recommended By; |
Name of Dr.(med) & address:
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| Are you taking medicine now or recently? | Please give details | |
Yes/No
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| Are you at present under treatment with a Dr or Hospital? | Please give details | |
Yes/No
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Have you had any of the following? (Leave blank if “No”) |
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| Heart murmur | Breathlessness | High Blood Pressure |
| Heart Pacemaker | Allergies to drugs | Drug Reactions |
| Diabetes | Chest trouble | Asthma |
| Epilepsy | Rheumatic fever | Jaundice |
| Bleeding problems especially after Dental extractions | ||
Other serious illness (Give Details)
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| Do you smoke? | If Yes how many; | |
Y/N
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Units of Alcohol per week ;
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| Your Smile | ||
| Are you happy with the colour of your teeth? | Y/N | |
| Would you like to lighten your teeth | Y/N | |
| Are you happy with the shape and position of the teeth | Y/N | |
| Would you like to change your smile? | Y/N | |
Please give details …..
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Date of last Dental appointment:
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| Are you pregnant? | If so, what is the est. birth date? | |
Y/N
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| Are you aware or suspect that you have contracted a blood-bourne virus such as Hepatitis or HIV? | ||
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Y/N
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| Any photographs taken of my dental treatment and smile may be used for demonstration purposes. | ||
Y/N
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As far as I am aware, the above is correct and I undertake to pay any charges accrued during my dental treatment, including for missed appointments.
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Signed;
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Date |