Mon – Fri – 9am to 5.30pm

N13 Dental ClinicOur patients smile with confidence

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HomeN13 Dental Clinic

N13 Dental Clinic

Medical History Form

Title

Surname

Forname

Address

Postcode

Tel no

Mobile no

Date of birth

Occupation

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

Practice Communications about appointments & treatments

sms

Marketing Communications

sms

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

Rheumatic fever?

YesNo

Any heart complaint, heart surgery or stroke?

YesNo

Diabetes?

YesNo

Epilepsy or fainting attacks?

YesNo

Chronic bronchitis or asthma?

YesNo

Hepatitis?

YesNo

Excessive bleeding?

YesNo

High blood pressure?

YesNo

Any other serious illness?

YesNo

Do you carry a medical warning card?

YesNo

Are you allergic to any medicine, tablets, substances or latex? list below)

YesNo

At present taking any medicine or tablets? (list below in notes)

YesNo

Pregnant

YesNo

In the past 2 years have you undergone any operations?

YesNo

Been treated with hydro-cortisone or corticosteroids?

YesNo

Have you ever had a joint replacement operation?

YesNo

Please tick or tell the dentist if you are HIV positive

YesNo

What is your average weekly consumption of alcohol?

If you smoke, what is your average per week?

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

Name and address of your doctor

Notes

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

Patient/Guardian Signature

Date

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