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Straightening
Implants
New Patients
Facial Aesthetics
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General
Cosmetic
Straightening
Implants
New Patients
Facial Aesthetics
- Dermal Fillers
- Anti Wrinkle Treatment

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3, Great Coleman Street, Ipswich, IP4 2AA
01473 597527

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MEDICAL HISTORY FORM

YOUR MEDICAL HISTORY

Please fill out and submit the following form before arrival at our surgery.

Title

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Please tick any of the following conditions which apply to you:

Conditions

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:

Allergies

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, allergies or medication?

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Quest Dental Ipswich, 3, Great Coleman Street, Ipswich, IP4 2AA 01473 597527 info@questdentalipswich.com

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Opening Hours
Monday – Friday:
8.30am – 5pm

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