Medical History Form

I give my consent to my contact details being used for the following: (please tick)

Certain medical conditions can affect dental treatments and vice versa

Please complete this form by ticking the appropriate boxes and answering the questions.

All details will be strictly confidential
Do you have or have you ever suffered from:

Yes No
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

If 'yes' to any questions please supply details in 'Notes/Medication List' below

If you are not sure of any of the questions, or if your medical circumstances change, please inform the Dental Surgeon