Online forms & Information

Medical history

This Medical History should be competed by NEW patients only. Existing patients should complete the Patient Triage form in the next tab.

ABOUT YOU

Your name

Address (including postcode)

Date of birth

Home phone number

Work phone number

Mobile phone number

Email address

Your occupation

Name and address of doctor

How did you hear about us?
WebsiteReferralAdvertisingOther

Please give more details, e.g. name of publication/name of referrer

DENTAL HISTORY & ORAL HYGIENE

What is the approximate date of your last dental examination?

How often did you attend?

Approximately when did you last have dental x-rays?

Do you have a dental insurance plan?
YesNo

Why have you changed your dentist?

Do you regularly see a dental therapist/hygienist?
YesNo

Are you experiencing any pain or discomfort with any of your teeth? Please give details.

Would you like to discuss any cosmetic treatments like teeth whitening? Please give details.

Is there anything else you would like to discuss about your oral health? Please give details.

MEDICAL HISTORY

Have you any history of any of the following?

High blood pressure:
YesNo
Please give details and medication.

Heart disease or angina:
YesNo
Please give details and medication.

Chest problems e.g. bronchitis/asthma:
YesNo
Please give details and medication.

Anaemia or blood disorders:
YesNo
Please give details and medication.

Excessive or persistent bleeding or bruising:
YesNo
Please give details and medication.

Liver disease or jaundice:
YesNo
Please give details and medication.

Infectious disease e.g. hepatitis/HIV/AIDS:
YesNo
Please give details and medication.

Kidney disease:
YesNo
Please give details and medication.

Diabetes:
YesNo
Please give details and medication.

Epilepsy or convulsions:
YesNo
Please give details and medication.

Fainting or other attacks:
YesNo
Please give details and medication.

Allergies e.g. penicillin/latex rubber/anaesthetics:
YesNo
Please give details and medication.

Any other serious illness?
YesNo
Please give details and medication.

Are you pregnant?
YesNo

Are you breast feeding?
YesNo

Do you smoke?
YesNo
Please give details of how much.

How many units of alcohol do you consume per week?

Please list any medication you are taking (if not already mentioned).

Are you happy to update us with your medication at each appointment?

All confidential, personal and sensitive personal information that you provide to us is stored, maintained, shared (e.g. a referral letter to a specialist, written on your behalf) and if necessary disposed of, under our 'Information Governance' system. We will only use your email address and your mobile phone number to contact you directly e.g. newsletters, appointment reminder texts etc. If for any reason we cannot get hold of you on your home/mobile number, would you have any objection to us calling another member of your family who are registered with the practice? This would only be for appointment changes or reminders.

Please tick to indicate that you understand and accept this

Please electronically sign in the box below:


Call us
01274 533933

Find out more
Book a consultation

Call us
01274 533933

Find out more
Book a consultation