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Dental Services medical history form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

Patient details

Name(Required)
Date of birth(Required)
Address(Required)
Preferred contact number
(Name and contact number)
Doctor's name and address(Required)
Please tick if appropriate...

Patient questions

Under the care of a doctor or the hospital for any condition? Have you ever been hospitalised or had an operation?(Required)
Have you ever been hospitalised?
Have you ever had an operation?
Taking any prescribed medicines or recreational drugs (e.g. tablets, injections,inhalers or patches)?(Required)
Had Covid-19 vaccine course?(Required)
Carrying a warning card including steroid warning care?(Required)
Pregnant or breastfeeding?(Required)
A signed DNAR CPR (Do not attempt resuscitate order or Advance Directive?)(Required)
If yes please show original to the dental team.
Allergies?(Required)
For example, antibiotics, food, latex, chlorhexidine or other substances.
Been on oral, inhaled or topical steroids within the last year?(Required)
Have you ever had an adrenal crisis?(Required)
Do you/the patient suffer/ever suffered from... Heart troubles of any kind, for example, angina, heart attack, murmur or birth defect? High or Low Blood Pressure? History of rheumatic fever/infective endocarditis? Chest trouble, for example, asthma, COPD, TB, sleep apnoea or bronchitis? Stomach or Intestine problems, for example, reflux, hernia, Crohn’s? Liver problems or investigation, for example, hepatitis, jaundice (except at birth) Kidney or bladder problems, for example, decreased kidney function or surgery? Epilepsy, fainting or blackouts? Multiple Sclerosis, Parkinson’s Disease, Motor Neurone Disease, Alzheimer’s Disease, Stroke, Memory problems or similar condition? Diabetes? Hepatitis or jaundice, (except at birth)? Any infectious diseases, including HIV? Bleeding disorders? Anaemia/blood disorder, for example, B12 deficiency, sickle cell? Liver or kidney disease? Any infectious diseases including HIV, MRSA? Bone disorders such as osteoporosis? Any hormone imbalances, for example, thyroid, Growth, Cortisol? Cancer Treatment, for example, Chemotherapy, Radiotherapy, Surgery, Bisphosphonates? Hay fever or Eczema? Does anyone have health and wellbeing lasting power of attorney for you/the patient? Or are there any behavioural factors?(Required)
Have you (or the patient) had... Allergies (e.g. antibiotics, food, latex or other substances), Hayfever or eczema, Joint replacements, implant, artificial valve or pacemaker, Heart Surgery, Brain Surgery, Growth hormone treatment, Cancer treatment e.g. radiotherapy, chemotherapy, iv bisphosphonates, A close relative (parent, sibling or grandparents) with Creutzfeldt Jacob disease or A signed DNAR CPR order.(Required)
If yes, please ensure a copy is brought to any appointments.

Diet and tooth brushing habits

How often do you have sweets and or chocolate/fizzy drinks?(Required)
Do you go to bed with a drink or drink in the night?(Required)

How often do you clean your teeth a day?(Required)
Do you use fluoride toothpaste?(Required)

Drinking and smoking

Do you drink alcohol?(Required)
Do you smoke any tobacco products now or did you in the past?(Required)
Do you chew tobacco, pan or supari now or did you in the past?(Required)
Do you vape/ heat not burn tobacco now or in the past?(Required)

Completed by

Completed by(Required)
Clear Signature
Select date DD slash MM slash YYYY

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