Medical History Form | Bearcross Dental Practice

Post Code: *

Gender: *

Male
Female
Other

Title *

Mr
Mrs
Miss
Master
Other

Full Name *

DOB: *

Address: *

Telephone Number: *

Email address

Preferred method of contact: *

By Mail
By Post
By SMS

Doctor: *

Address: *

Contact Number: *

Do you carry a medical warning card? *

Yes
No

Please give details:

Occupation: *

Next of Kin: *

Relationship to you: *

Contact Number: *

Medical Details: Please tick if applicable *

Anaemia
Diabetes (or anyone in your family)
Epilepsy/fainting attacks/blackouts
Cancer
Brain Surgery
Arthritis
Cold Sores
Hay fever/eczema
Gastric Disease
Drug Dependence
Heart Condition/Attack/Murmur/Angina/Stroke
Rheumatic fever or Chorea/ St Vitus Dance
Liver or kidney problems including hepatitis/ jaundice
TB or chest problems including asthma/ bronchitis
Joint replacement or other implant
Bad reaction to local or general anaesthetic
Blood refused by the Blood Transfusion Service
Growth hormone treatment before the mid 1980's?
Close relative (parent,sibling,child,grandparent or grandchild) with Creutzfeldt Jajob Disease (CJD)
Steroid treatment
Treatment that required you to stay in hospital
Please tick or tell your dentist if you are HIV positive
None of the above

Are you allergic to any medicines, tablets, substances or latex? If so, which? *

Do you think or are you aware that you may be pregnant? *

Yes
No

Do you smoke? *

Yes
No

If so, how many cigarettes do you smoke on average in a week?

Do you drink? *

Yes
No

If so how many units of alcohol do you drink per week?

Please provide further details on any of the above medical problems and/or any medication you are currently taking:

Dental history - do you have or have you had any of the following? *

Pain or discomfort in your teeth
Sensitivity in your teeth
Bleeding when brushing/ flossing
Headaches/ migraines
Unpleasant taste/ odour in your mouth
Food often stuck between teeth
Mouth ulcers/ cold sores
Grinding teeth/ clenching jaw
None of the above

COVID-19 Screening Questions *

Have you tested positive for COVID-19 in the last 7 days?
Are you waiting for a COVID-19 test or the results?
Do you have any of the following symptoms: • New, continuous cough*; • High Temperature or fever; • Loss of or change in sense of smell or taste?
Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?
Have you been notified by NHS Test and Trace in the last 14 days that you are a contact of a person who has tested positive for COVID-19 and you do not live with that person?
None of the above

Medical History Form Updates (For Follow-up Appointments) Please sign below to certify that the information in this Medical History Form is still accurate and up-to-date. If there are any changes in your health, please provide us with details.

Name

Date:

Patient/ Parent/ Guardian:

Signature:

Please sign below to certify that you have read and understood the above information and that all of your answers are accurate and up-to-date. Any incorrect information can be dangerous to your health and you must inform us of any changes *

Patient/ Parent/ Guardian *

Signed *