- Confidential Medical History -

- Confidential Medical History -

Please complete the following medical questionnaire about your health to help us provide you with safe dental care. Please ensure that these are the most accurate information.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date

Medical Questionnaire *

Yes

If Yes, please give details?

Epilepsy, Fits or Faints?

Heart or Blood Pressure Problems?

Lung, Asthma or Breathing Problems (Including Bronchitis)?

Liver disease (Including Hepatitis or Jaundice) or Kidney disease?

Bleeding disorder or tendency, e.g. persistent bleeding after injury, tooth extraction or surgery?

Diabetes?

Bone or joint disease?

Infectious diseases e.g HIV or Hepatitis?

Any allergies e.g Penicillin?

Take Bisphosphonate therapy or drug treatment for Cancer, Paget's disease or Osteoporosis?

Take blood thinning tablets or injection. E.g. Warfarin or Heparin?

Take any steroids, if so what for?

Past operations or treatment that required you to be in hospital?

A bad reaction to Local or General anaesthetic?

Mental health problems, Dementia or Alzheimer's diseases?

Any other illness or disabilities we should be aware of?

Are you currently receiving treatment from a Doctor, Hospital or clinic?

Are you currently using prescribed medication including inhalers / drugs / creams?

Are you currently carrying a medical warning card?

Are you currently pregnant or breast feeding?

Do you smoke - how many per week?

Do you chew tobacco / paan or use Gutka or Supari?

Do you drink alcohol? If so how much per week?

Please list all prescribed medication/inhalers/creams- Include Dose & Frequency
Signature *

By signing above, you confirm that all the information above is the most up to date and accurate information, should anything change, you MUST report this to the dental practice by submitting a new medical history. Clear
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