MEDICAL HISTORY FORM Email Your Details First Name * Last Name * Email Address * Phone Number Address * Post Code * Doctors Name & Address * Occupation * It is important, for your benefit, that your dentist knows certain things about your general health. It would be appreciated therefore if you would answer each of the questions below by ticking “yes” or “no” and giving details below where appropriate. Your co-operation is much appreciated. Are you recieving treatment from a hospital, doctor or clinic? YesNo Are you taking any medicines prescribed by your doctor? YesNo Are you taking (or have taken) steroids in the last two years? YesNo Are you receiving or taking bisphosphonates by infusion or tablets? YesNo Are you allergic to any medicines or materials e.g. antibiotics or latex? YesNo Are you pregnant or have you had a baby in the last 12 months? YesNo Please provide details for any Have you had Rheumatic Fever? YesNo Have you had Jaundice, liver, kidney disease or hepatitis? YesNo Have you ever been told you have a heart problem, angina, or high blood pressure? YesNo Have you ever had a bad reaction to local anaesthetic? YesNo Have you ever a joint replacement or other implant? YesNo Have you ever hospitalised? If YES for what and when? YesNo Please provide details for any Do you have arthritis? YesNo Do you have a Pacemaker? YesNo Do you suffer from hay fever, eczema, or any other allergy? YesNo Do you suffer from bronchitis, asthma, or any other chest condition? YesNo Do you have diabetes? YesNo Do you have persistent bleeding following injury,tooth extraction or surgery? YesNo Do you suffer from any infectious disease (including H.I.V)? YesNo Do you have a close relative with Creutzfeld Jakob Disease? YesNo Do you carry a warning card? YesNo Do you smoke? If yes, approximately how many each day? YesNo Do you drink alcohol? If yes, approximately how many units each week? YesNo Please provide details for any Please give any other details which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin) or treatments or medicines that you prefer not to have for religious or personal reasons?
