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.

Title

Name *

First

Last

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?

You are at higher risk of COVID-19 if you answer 'yes' to any of the following:

Have you had a new continuous cough, a temperature (more than 37.8 C) or a change in the sense of smell or taste? Have you or a member of your household/care home have tested positive for COVID-19, or have been told to isolate by the 'track & trace' program, and you/they are still in the isolation period? Are you waiting for the results of a PCR test? Have you travelled internationally in the last 10 days to a country that is on the 'red list'?

Are you at higher risk of COVID-19? *

We need to screen you and your household/care home for COVID-19

Are you in a special category group for COVID-19? *

Yes, I used to be shielded (currently extremely high risk)
Yes, I am at high risk due to my age and/or condition(s)
No

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
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

Details of Medical Conditions

Domiciliary visit requested due to: *

Mental Disability
Physical Disability
Extremely high/high risk (COVID-19)

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
Endoxaban
Rivaroxaban
Dabigatran
Dalteparin
Enoxaparin
Tinzaparin

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 other medication or alternative medicines you take

Have you got any dental issues that need to be addressed?

Please give details of any current dental issues

Upload a file

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

E.g. scan of a repeat prescription, any Xrays, pictures, etc. 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