Medical History Form

Your Medical History

Our medical questionnaire is now digital.

Full Name

Email

Phone Number

DOB

Full Address

Occupation

Are you a den plan member?

Do you claim any benefits?

When did you last visit the dentist?

Name of Doctor

Address of Doctor

Diabetes

Yes No

Arthritis

Yes No

Epilepsy, blackouts, giddiness, or fainting

Yes No

Rheumatic Fever

Yes No

Chronic Bronchitis, Asthma, or any other Respiratory Disease

Yes No

Hepatitis, Jaundice, Liver, or Kidney Disease

Yes No

High blood pressure or Angina

Yes No

Heart Disease, Heart Attack, or any related complaints

Yes No

Has had Heart/Pace-maker surgery

Yes No

Steroid Therapy has been administered in past two years

Yes No

Persistent mouth ulcer lasting more than 3 weeks

Yes No

HIV Positive

Yes No

Any Allergies

Yes No

Ever had allergic reactions to Local or General Anaesthetic

Yes No

Recently undergone any blood tests

Yes No

Excessive bleeding and/or bleeding disorders

Yes No

Are you pregnant or have had a baby in the last 12 months

Yes No

Undergone a joint replacement operation

Yes No

Are you currently undergoing any Medical Treatment

Yes No

At present undertaking medication?

Yes No

Undergone hospitalisation that may affect dental care

Yes No

Any other serious illness or related medical condition

Yes No

If you smoke, how many per day?

What is average weekly consumption of alcohol?

Please List any medication you are taking

Please tick this box to confirm the details are correct

Confirmed

Your Medical History