Medical History Form Step 1 of 250%HiddenDate MM slash DD slash YYYY Surname*First name(s)*Title*Sex* Male Female Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the patient’s weight likely to be more than 22 st/140 kg?* Yes NoNHS NumberAddress*Please complete all fields Street Address Address Line 2 Town/City County Post code Email* Enter Email Confirm Email Home tel. no.*Mobile number*Is the patient happy to receive SMS (text) notifications? Yes NoIf yes, please give a mobile telephone for SMS (text) notificationsWhere have you lived in the past 12 months?*Occupation or school*Next of kin name*Contact Tel*Relationship of next of kin to the patient*Doctor’s name, address & tel no*Do you have a social worker?* Yes NoPlease give name & numberDo you have a Lasting Power of Attorney for health?* Yes NoPlease give name & numberHow long is it since you last received dental treatment?*Where was this?*ETHNIC ORIGIN* White British White Irish Other White Background White and Black African White and Black Caribbean White and Asian Other Mixed Background Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Other Asian Background Black or Black British Caribbean Black or Black British African Other Black Background Chinese Any other Ethnic Group Patient Declined to answerRELIGION* Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Patient Declined to answerCompleted by* Self Parent GuardianWhom may we speak to about the patient, if you are unavailable?Name*Relationship to the patient*Tel. no*PATIENT MEDICAL HISTORY FORMHas the patient ever been admitted to hospital?* Yes NoDetails - please stateHas the patient had any operations?* Yes NoDetails - please stateIs this patient attending or receiving treatment from a doctor, hospital, clinic or specialist?* Yes NoDetails - please stateHas the patient had a bad reaction to a general or local anaesthetic?* Yes NoDetails - 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 NoPlease bring repeat prescription/MARS sheet (if applicable)Details - please stateIs the patient taking or has taken steroids in the last two years?* Yes NoDetails - please stateIs the patient using or has ever used recreational drugs?* Yes NoDetails - please stateIs patient allergic to any medicines or food substances?* Yes NoDetails - please stateDoes the patient suffer from Parkinson’s disease, motor neurone disease, or other neurological condition?* Yes NoDetails - please stateHas the patient ever been told they have a heart murmur, heart disease, high blood pressure, angina, heart attack, stroke or heart surgery?* Yes NoDetails - please stateDoes the patient have a pacemaker, VNS, stent, artificial valve, shunt or other form of implanted medical device?* Yes NoDetails - please stateHas the patient ever had liver, kidney disease or hepatitis?* Yes NoDetails - please stateDoes the patient suffer from allergies e.g hay fever or eczema?* Yes NoDetails - please stateDoes the patient suffer from bronchitis, asthma or other chest conditions?* Yes NoDetails - please stateDoes the patient have fainting attacks, giddiness, blackouts or epilepsy?* Yes NoDetails - please stateDoes the patient have diabetes?* Yes NoDetails - please stateDoes the patient have anaemia?* Yes NoDetails - please stateHas the patient ever bled excessively?* Yes NoDetails - please stateDoes the patient live with any infectious diseases (including HIV, Hepatitis B or C)?* Yes NoDetails - please stateHas the patient ever received growth hormone treatment?* Yes NoDetails - please stateDoes the patient carry a warning card or a medi alert?* Yes NoDetails - please stateDoes the patient have a TEP (Treatment Escalation Plan) – sometimes known as DNAR (Do Not Attempt Resuscitation)?* Yes NoDetails - please stateDoes the patient drink alcohol?* Yes NoDetails - how many units per weekDoes the patient smoke or chew tobacco products, use Vape or hookah* Yes Noif so, how many per week?Does the patient wish to receive advice about stopping smoking?* Yes NoDetails - please stateDoes the patient have any physical, visual or hearing problems?* Yes NoDetails - please stateDoes the patient have any behavioural or learning disabilities such as Autism Spectrum Condition, or ADHD?* Yes NoDetails - please stateHas the patient ever had any mental health problems, including anxiety and panic attacks?* Yes NoDetails - please stateIs the patient pregnant or breastfeeding?* Yes NoDetails - please stateIs there anything else the dentist should know?* Yes NoDetails - please stateLast updated: October 7, 2020
