Patient medical history

This Medical History should be competed by new patients and by existing patients who need to update their medical history.

    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: