Medical History Form

To enable us to treat our patients in a safe and appropriate manner, we require our patients or their representatives to fill out a concise medical history form and send it to us, ideally prior to our visit to them to alert our dentists and staff to any potential problems we may come across. Please fill in the form entirely and as accurately as possible.

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Title

Name *

First

Last

Goes by the name of:

If the patient likes to be known by a name other than their official name, please enter this here, otherwise leave blank

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Telephone number *

The best number for us to reach you on

Alternative telephone number

In case we cannot reach you on the primary number

Email Address

GP Details

The GP surgery you are registered with, just in case we need to contact them

Is The Patient Entitled to Free NHS Dental Care?

Please answer this question accurately. Inappropriately claiming free dental care may leave you liable to a fine by the NHS Business Services Authority. Please note that old age does not automatically entitle you to free dental care

Domiciliary visit requested due to: *

Mental Disability, patient cannot go out
Physical Disability, patient cannot go out

Domiciliary care is only available to patients who by virtue of a temporary or permanent mental or physical disability are unable to leave their home environment to receive dental care, or are over the age of 90. Prospective patients who go out regularly for leisure are NOT eligible for domiciliary care

Which of the following conditions do you/have you suffer/ed from? (Please give details)

Medical Conditions *

No Relevant Medical History
Medical Conditions Specified Below

Are you allergic to anything that you know of? *

What are you allergic to? *

Give details of any known allergies

Medical Conditions

Asthma
Other Lung Conditions
Angina
Heart Conditions
Rheumatic Fever or Chorea
History of Infective Endocarditis
Pacemaker
High Blood Pressure
Stroke or TIA
Heart Valve Problems
Blood-Borne Infections (e.g. Hepatitis, HIV etc)
Jaundice or Liver Disease
Impaired Liver Function
Epilepsy
Impaired Kidney Function
Diabetes
Gastric Ulceration
A Bad Reaction to Local Anaesthetic
A Bad Reaction to Genral Anaesthetic
Eczema
Bleed or Bruise Easily
Familial Bleeding Conditions (e.g. Hemophilia)
Any Surgery or Stay in Hospital
Dementia
Any Other Medical Conditions

Please Give Details Of All Conditions You Selected (Please Avoid Abbreviations)

Details of Medical Conditions

What Is Your Drug History?

Do you take any blood thinners?

Which blood thinner/s do you take?

Aspirin
Clopidogrel
Dipyridamole
Prasugrel
Tricagrelor
Warfarin
Acenocoumarol
Phenindione
Apixaban
Edoxaban
Rivaroxaban
Dabigatran
Dalteparin
Enoxaparin
Tinzaparin

Do you take (or have you taken) any bisphosphonates, any Anti-Angiogenic drugs or RANKL inhibitors?

Which drug do you take or have you taken?

Alendronate
Sodium clodronate
Disodium etidronate
Ibandronate
Risedronate sodium
Ibandronate (Intravenous)
Disodium pamidronate (Intravenous)
Zoledronic acid (Intravenous)
Bevacizumab
Sunitinib
Aflibercept
Denosumab

Have you taken steroids in the past 2 years?

What steroids do/did you take and what dosage?

Give details of any steroid dosage

Do you carry a medical warning card?

What does the warning card state?

Give details of any medical warning cards

Do you take any other medication?

Do you take any 'alternative medication'?

Including illicit or 'off-label' medication

Please give details of any medication or alternative medicines you take *

Please note that a completed medical history form constitutes a legal document. All medication a patient takes MUST be detailed here. It is NOT acceptable to say 'refer to MAR chart or prescription on arrival'.

Why does the patient need to be seen by a dentist? *

Upload a file

Click or drag files to this area to upload. You can upload up to 3 files.

Any Xrays, pictures of the mouth or denture. Please DO NOT attach pictures of prescriptions. Extensions allowed: jpg, png, bmp, pdf, tif, tiff

Alcohol Consumption

Selected Value: 0

Units Per Week

Tobacco Usage

Selected Value: 0

Times Per Day

Who is filling in this form?

Your name and relationship to the patient *

Date Completed *

GDPR Agreement *

I consent to having this website store my submitted information so they can process my request