Medical History Form
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MOBILE: M/F OCCUPATION: NEXT OF KIN (NAME PHONE N O): EXPECTANT MOTHER: Y/NHOW LONG SINCE LAST RECEIVED DENTAL TREATMENT: YOUR GP’S NAME AND ADDRESS: YES NO DETAILS ARE YOU Attending or receiving treatment from doctor, hospital, clinic or specialist 2 Taking any medicines from your doctor (tablets, creams, injections, other) 3 Taking or taken steroids in the last two years 4 Allergic to any medicines, foods or materials HAVE YOU 1 Had Rheumatic fever or Chorea (St.Vitus dance) 2 Had jaundice, liver, kidney disease or hepatitis 3 Ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack 4 Had any infectious diseases (including Hepatitis HIV) 5 Had a bad reaction to a general or local anaesthetic 6 Been hospitalised If YES what for and when DO YOU 1 Have a hip replacement 2 Have a pacemaker, or have you had any form of heart surgery 3 Suffer from hay fever, eczema or any other allergy 4 Suffer from bronchitis, asthma or any other chest condition 5 Have fainting attack, giddiness, blackouts or epilepsy 6 Do you or any member of your family suffer from diabetes 7 Bruise easily or following a tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried 8 Carry a warning card 9 Ever get cold sores 10 How many units of alcohol do you drink per week 11 Do you smoke any tobacco products now (did you in the past ) If yes, how many per day Are there any other aspects concerning your health that you think the dentist should know about I understand that my dentist may discontinue treatment if Ifail to turn up to appointment(s) or fail to give 8 hours cancellation notice..
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