Medical History Form

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Title(Required)

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

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

I consent to my data being used in accordance to the Privacy Policy.

Signed by

Date

DD slash MM slash YYYY

YOUR MEDICAL HISTORY

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