Medical History Form

PATIENT MEDICAL HISTORY FORM

Has the patient ever been admitted to hospital?*

Yes
No

Details - please state

Has the patient had any operations?*

Yes
No

Details - please state

Is this patient attending or receiving treatment from a doctor, hospital, clinic or specialist?*

Yes
No

Details - please state

Has the patient had a bad reaction to a general or local anaesthetic?*

Yes
No

Details - where, when and what for?

Is the patient taking any medicines (tablets, creams, ointments, injections, other – including Warfarin, aspirin, contraceptives and HRT) or alternative remedies?*

Yes
No

Please bring repeat prescription/MARS sheet (if applicable)

Details - please state

Is the patient taking or has taken steroids in the last two years?*

Yes
No

Details - please state

Is the patient using or has ever used recreational drugs?*

Yes
No

Details - please state

Is patient allergic to any medicines or food substances?*

Yes
No

Details - please state

Does the patient suffer from Parkinson’s disease, motor neurone disease, or other neurological condition?*

Yes
No

Details - please state

Has the patient ever been told they have a heart murmur, heart disease, high blood pressure, angina, heart attack, stroke or heart surgery?*

Yes
No

Details - please state

Does the patient have a pacemaker, VNS, stent, artificial valve, shunt or other form of implanted medical device?*

Yes
No

Details - please state

Has the patient ever had liver, kidney disease or hepatitis?*

Yes
No

Details - please state

Does the patient suffer from allergies e.g hay fever or eczema?*

Yes
No

Details - please state

Does the patient suffer from bronchitis, asthma or other chest conditions?*

Yes
No

Details - please state

Does the patient have fainting attacks, giddiness, blackouts or epilepsy?*

Yes
No

Details - please state

Does the patient have diabetes?*

Yes
No

Details - please state

Does the patient have anaemia?*

Yes
No

Details - please state

Has the patient ever bled excessively?*

Yes
No

Details - please state

Does the patient live with any infectious diseases (including HIV, Hepatitis B or C)?*

Yes
No

Details - please state

Has the patient ever received growth hormone treatment?*

Yes
No

Details - please state

Does the patient carry a warning card or a medi alert?*

Yes
No

Details - please state

Does the patient have a TEP (Treatment Escalation Plan) – sometimes known as DNAR (Do Not Attempt Resuscitation)?*

Yes
No

Details - please state

Does the patient drink alcohol?*

Yes
No

Details - how many units per week

Does the patient smoke or chew tobacco products, use Vape or hookah*

Yes
No

if so, how many per week?

Does the patient wish to receive advice about stopping smoking?*

Yes
No

Details - please state

Does the patient have any physical, visual or hearing problems?*

Yes
No

Details - please state

Does the patient have any behavioural or learning disabilities such as Autism Spectrum Condition, or ADHD?*

Yes
No

Details - please state

Has the patient ever had any mental health problems, including anxiety and panic attacks?*

Yes
No

Details - please state

Is the patient pregnant or breastfeeding?*

Yes
No

Details - please state

Is there anything else the dentist should know?*

Yes
No

Details - please state

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Whom may we speak to about the patient, if you are unavailable?

PATIENT MEDICAL HISTORY FORM