Dental Services medical history form

Patient details

Name*

Firstname Surname

Title

Date of birth*

Address*

Street address 1 Street address 2 Town County Postcode

Phone*

Preferred contact number

School (if applicable)

NHS number

Next of kin details*

(Name and contact number)

Doctor's name and address*

Name Address Town County Postcode

Doctor's phone*

Any social workers details

Height*

Weight*

Please tick if appropriate...

Physically disabled
Wheelchair user (add details below if they can transfer on their own)
Medically compromised
Learning disability (please specify below)
Blind
Deaf
Other communication needs (for example, braille, makaton, BSL, translator)

Please add details if needed

Patient questions

Under the care of a doctor or the hospital for any condition? Have you ever been hospitalised or had an operation?*

Yes
No

Please give details*

Have you ever been hospitalised?

Yes
No

Please give details*

Have you ever had an operation?

Yes
No

Please give details*

Taking any prescribed medicines or recreational drugs (e.g. tablets, injections,inhalers or patches)?*

Yes
No

Please give details*

Had Covid-19 vaccine course?*

Yes
No

Please give details*

Carrying a warning card including steroid warning care?*

Yes
No

Please give details*

Pregnant or breastfeeding?*

Yes
No

Please give details*

A signed DNAR CPR (Do not attempt resuscitate order or Advance Directive?)*

Yes
No

If yes please show original to the dental team.

Allergies?*

For example, antibiotics, food, latex, chlorhexidine or other substances.

Yes
No

Please give details*

Been on oral, inhaled or topical steroids within the last year?*

Yes
No

Please give details*

Have you ever had an adrenal crisis?*

Yes
No

Please give details*

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?*

Please add details

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.*

Please add details

Please give us a list of medications you are taking and any further information that may assist us in treating you*

Are there any behavioural factors the dentist needs to know*

Are there any risk assessments in place for the patient?*

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?*

More than once a day
Everyday
2-3 times a week
Weekends only
Very occasionally

Do you go to bed with a drink or drink in the night?*

How often do you clean your teeth a day?*

0
1
2
3 or more

Do you use fluoride toothpaste?*

Yes
No
Don't know

Drinking and smoking

Do you drink alcohol?*

Yes
No

How many units of alcohol do you drink per week?*

(A unit is half a pint of larger, a single measure of spirits or a single glass of wine/aperitif)

Do you smoke any tobacco products now or did you in the past?*

Yes
No

Do you chew tobacco, pan or supari now or did you in the past?*

Yes
No

Do you vape/ heat not burn tobacco now or in the past?*

Yes
No

Completed by

Completed by*

Self
Parent
Guardian

Signature

Date*

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Dental Services medical history form

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Patient details

Patient questions

Diet and tooth brushing habits

Drinking and smoking

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