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01473 597527
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3, Great Coleman Street, Ipswich, IP4 2AA
MEDICAL HISTORY FORM
YOUR MEDICAL HISTORY
Please fill out and submit the following form before arrival at our surgery.
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3
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Title
(Required)
Title
Mr
Mrs
Miss
Master
Dr
Full Name
(Required)
Date Of Birth
DD slash MM slash YYYY
Address
Town/City
Postcode
Email
(Required)
Phone
(Required)
Occupation
Name of Doctor
Address of Doctor
Next of Kin
Relationship to Next of Kin
Telephone of Next of Kin
When did you last visit the dentist?
DD slash MM slash YYYY
Are you a Den Plan Member?
Yes
No
Please tick any of the following conditions which apply to you:
I am pregnant/possibly pregnant or have had a baby in the past 12 months
I have antibiotic cover requirement
I bruise easily or suffer persistent bleeding following a tooth extraction or injury
I am currently receiving treatment by a doctor, hospital or clinic
I am not OK to recline on dental chair
I am taking or have taken steroids in the past 2 years
I carry a medical warning card
I have been on a treatment requiring hospitalisation in the last 2 years
I have rheumatic fever or chorea
I have high blood pressure
I have had heart surgery or a heart stroke
I have a pacemaker fitted
I have a heart murmur
I have angina
I have thrombosis
I have another heart condition
I have bronchitis
I have cystic fibrosis
I have pleurisy
I have asthma
I have emphysema
I have pneumonia
I have had chest surgery or other chest conditions
I have liver disease (e.g jaundice, hepatitis)
I have diabetes (or someone in my family does)
I have acid reflux or an eating disorder
I have a bone or joint disease
I have fainting attacks or blackouts
I have had a serious or infectious disease
I have kidney disease
I have epilepsy
I have hiatus hernia
I have an artificial joint or other implants
I have giddiness
I have cancer
I require special needs (nervous, anxious, phobic)
My mother/siblings have a high number of caries
I have hepatitis B
I have H.I.V
I have had an abnormal blood test
I have had a reduced blood transfusion
I have anaemia
I have sickle cell
I have haemophilia or any other blood conditions
Please tick any of the following allergies which apply to you:
Are you allergic to penicillin?
Are you allergic to hay fever?
Are you allergic to anti tetanus serum?
Are you allergic to eczema?
Are you allergic to general anaesthetic?
Are you allergic to local anaesthetic?
Are you allergic to latex?
Are you allergic to medicines?
Are you allergic to plants?
Are you allergic to any foods?
Are you allergic to aspirin?
If you smoke, how many per day?
What is your average weekly consumption of alcohol?
Please list any medication you are taking
Any other conditions or medication?
Please tick this box to confirm that the information submitted is correct
Please tick this box to confirm that the information submitted is correct
I consent to my data being used in accordance to the Privacy Policy.
I consent to my data being used in accordance to the Privacy Policy.
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