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)

Firstname Surname

Title

Date of birth(Required)

Address(Required)

Street address 1 Street address 2 Town County Postcode

Phone(Required)

Preferred contact number

School (if applicable)

NHS number

Next of kin details(Required)

(Name and contact number)

Doctor's name and address(Required)

Name Address Town County Postcode

Doctor's phone(Required)

Any social workers details

Height(Required)

Weight(Required)

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?(Required)

Yes

Please give details(Required)

Have you ever been hospitalised?

Yes

Please give details(Required)

Have you ever had an operation?

Yes

Please give details(Required)

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

Yes

Please give details(Required)

Had Covid-19 vaccine course?(Required)

Yes

Please give details(Required)

Carrying a warning card including steroid warning care?(Required)

Yes

Please give details(Required)

Pregnant or breastfeeding?(Required)

Yes

Please give details(Required)

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

Yes

If yes please show original to the dental team.

Allergies?(Required)

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

Yes

Please give details(Required)

Been on oral, inhaled or topical steroids within the last year?(Required)

Yes

Please give details(Required)

Have you ever had an adrenal crisis?(Required)

Yes

Please give details(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)

Heart troubles of any kind e.g. 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 investigations, 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?

Hayfever or Eczema?

Does anyone have health and wellbeing lasting power of attorney for you/the patient? If yes please provide details.

Are there any behavioural fators or other information the dentist needs to know?

None

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.(Required)

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?

A signed DNAR CPR (Do Not Attempt to Resuscitate) order

None

Please add details

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

Are there any behavioural factors the dentist needs to know(Required)

Are there any risk assessments in place for the patient?(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)

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?(Required)

Water

Plain milk

Flavoured milk

Squash

Nothing

Other

How often do you clean your teeth a day?(Required)

3 or more

Do you use fluoride toothpaste?(Required)

Yes

Don't know

Drinking and smoking

Do you drink alcohol?(Required)

Yes

How many units of alcohol do you drink per week?(Required)

(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?(Required)

Yes

Do you chew tobacco, pan or supari now or did you in the past?(Required)

Yes

Do you vape/ heat not burn tobacco now or in the past?(Required)

Yes

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Completed by(Required)

Self

Parent

Guardian

Signature

Date(Required)

DD slash MM slash YYYY

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Dental Services medical history form

Your information

Patient details

Patient questions

Diet and tooth brushing habits

Drinking and smoking

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