Medical History Form Step 1 of 250%SurnameFirst name(s)TitleSexMaleFemaleDate of birth Date Format: DD slash MM slash YYYY Is the patient’s weight likely to be more than 22 st/140 kg?YesNoNHS NumberAddress Street Address Address Line 2 Town/City County Post code Email Enter Email Confirm Email Home tel. no.Mobile numberIs the patient happy to receive SMS (text) notifications?YesNoWhere have you lived in the past 12 months?Occupation or schoolNext of kin nameContact TelRelationship of next of kin to the patientDoctor’s name, address & tel noDo you have a social worker?YesNoPlease state nameHow long is it since you last received dental treatment?Where was this?ETHNIC ORIGINWhite BritishWhite IrishOther White BackgroundWhite and Black AfricanWhite and Black CaribbeanWhite and AsianOther Mixed BackgroundAsian or Asian British IndianAsian or Asian British PakistaniAsian or Asian British BangladeshiOther Asian BackgroundBlack or Black British CaribbeanBlack or Black British AfricanOther Black BackgroundChineseAny other Ethnic GroupPatient Declined to answerRELIGIONAtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismPatient Declined to answerCompleted bySelfParentGuardianWhom may we speak to about the patient, if you are unavailable?NameRelationship to the patientTel. noPATIENT MEDICAL HISTORY FORMHas the patient ever been admitted to hospital?YesNoDetails - please stateHas the patient had any operations?YesNoDetails - please stateIs this patient attending or receiving treatment from a doctor, hospital, clinic or specialist?YesNoDetails - please stateHas the patient ever had a general anaesthetic?YesNoDetails - where, when and what for?Has the patient had a bad reaction to a general or local anaesthetic?YesNoDetails - please stateIs the patient taking any medicines (tablets, creams, ointments, injections, other – including Warfarin, aspirin, contraceptives and HRT) or alternative remedies?YesNoPlease bring repeat prescription/MARS sheet (if applicable)Details - please stateIs the patient taking or has taken steroids in the last two years?YesNoDetails - please stateIs the patient using or has ever used recreational drugs?YesNoDetails - please stateIs patient allergic to any medicines or food substances?YesNoDetails - please stateDoes the patient suffer from Parkinson’s disease, motor neurone disease, or other neurological condition?YesNoDetails - please stateHas the patient ever been told they have a heart murmur, heart disease, high blood pressure, angina, heart attack, stroke or heart surgery?YesNoDetails - please stateDoes the patient have a pacemaker, VNS implant, stent, artificial valve, shunt, or other form of implant?YesNoDetails - please stateHas the patient ever had jaundice, liver, kidney disease or hepatitis?YesNoDetails - please stateDoes the patient suffer from allergies e.g hay fever or eczema?YesNoDetails - please stateDoes the patient suffer from bronchitis, asthma or other chest conditions/snoring/sleep apnoea?YesNoDetails - please stateDoes the patient have fainting attacks, giddiness, blackouts or epilepsy?YesNoDetails - please stateDoes the patient have diabetes?YesNoDetails - please stateDoes the patient have anaemia?YesNoDetails - please stateHas the patient ever bled excessively?YesNoDetails - please stateDoes the patient suffer from any infectious diseases (including HIV, Hepatitis B or C)?YesNoDetails - please stateHas the patient ever been notified for public health purposes that they are at risk of CJD or vCJD?YesNoDetails - please stateDoes the patient carry a warning card or a medi alert?YesNoDetails - please stateDoes the patient have a TEP (Treatment Escalation Plan) – sometimes known as DNAR (Do Not Attempt Resuscitation)?YesNoDetails - please stateDoes the patient drink alcohol?YesNoDetails - how many units per weekDoes the patient smoke or chew tobacco products, use Vape or hookahYesNoif so, how many per week?Does the patient wish to receive advice about stopping smoking?YesNoDetails - please stateDoes the patient have any physical, visual or hearing problems?YesNoDetails - please stateDoes the patient have any behavioural or learning disabilities?YesNoDetails - please stateDoes the patient have an Autism Spectrum Condition, or ADHD?YesNoDetails - please stateHas the patient ever had any mental health problems, including anxiety and panic attacks?YesNoDetails - please stateIs the patient pregnant or breastfeeding?YesNoDetails - please stateIs there anything else the dentist should know?YesNoDetails - please state Last updated: October 7, 2020
