Medical History Form: Dental
Please note: You only need to fill this form in if you have a dental appointment. For facial aesthetic or medical aesthetic appointments, please fill out the Medical Aesthetics Medical History Form here.
Full Name *
First
Last
Date of Birth *
Occupation *
Address *
Phone (Home) *
Phone (Mobile) *
Email *
Emergency Contact (Please provide name, relationship to patient and contact information)
Where did you hear about us? *
- Google/website
- Social media (Facebook/Instagram)
- Newspaper/Magazine
- Sign/building
- Another patient/friend
Name of your GP
GP Surgery Address *
GP Surgery Phone Number *
Have you ever had any of the following? Please tick all that apply:
- High blood pressure
- Bleeding disorder
- Excessive bleeding
- Epilepsy/seizures
- Psychological disorders
- Diabetes
- Dizziness
- Hearing or speech problems
- Fainting/low blood pressure
- Glaucoma
- Heart disease
- Heart murmur
- Hepatitis A, B or C
- Kidney disease
- Liver disease
- HIV/AIDS
- Asthma
- Pacemaker
- Cancer
- Stroke
- Rheumatic fever
- Respiratory problems
- Sinus problems
- Tuberculosis
- Anaemia
- Herpes (cold sores)
Do you have any allergies? If yes, please specify:
Are you pregnant or currently breastfeeding? *
- Yes
- No
Have you had a serious illness or been in hospital in the last 5 years? If yes please provide information:
Are you currently taking any medication? If yes, please list so that we can add onto your patient notes):
Do you smoke? *
- Yes
- No
If you answered yes above, please let us know how much you smoke on a daily average:
Do you drink alcohol? *
- Yes
- No
If you answered yes above, please let us know how many units you consume on a weekly average:
Are you concerned about or experiencing any of the following dental issues? (Tick all that apply)
- Sensitivity to cold/hot
- Sensitivity when eating
- Staining on teeth
- Bleeding gums
- Head/neck ache
- Food trapping between teeth
- Discoloured fillings
- Bad breath
- Grinding teeth/clenching jaw
- Severe pain/swelling
- Clicking pain in jaw joints
- Rough/broken fillings or teeth
Please tick all that apply.
Are you concerned with any of the following? (Tick all that apply)
- Existing crowns/bridge/denture
- Discolouration of teeth
- Ability to eat
- Your smile
- Gaps between your teeth
- Silver fillings
- Previous dental treatment
- Crooked teeth
When was your last Dental visit? *
What is the main purpose of your visit today? *
Does dental treatment make you feel nervous? *
- Yes, extremely
- Sometimes
- No, not at all
Have you had / do you require sedation for any dental treatment? *
- Yes
- No
If the patient is under 18, please provide the Parent/Guardian details (Name, address, telephone number)
I confirm that I am happy to be contacted by e-mail and I understand that the practice has taken the necessary steps to make this method of contact as secure as possible (however I understand that this cannot be guaranteed). *
- I confirm
I have completed this medical/dental history form and confirm that this information is true and correct to the best of my knowledge at the present date. I have been informed that I am to review, update and sign a new medical history form at all further examination or consultation appointments in line with practice policy. *
- I confirm
Signed by (enter full name) *
First
Last
Date *
Dental Clinician Signature
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