Medical History Form Go backYour message has been sent Patient Details Title Mr Mrs Miss Dr Ms Master Prefer not to say Warning Name(required) Warning Warning Email(required) Warning Gender(required) Male Female Non Binary Warning Date of Birth(required) Warning Home Address(required) Warning Phone Number(required) Warning Occupation Warning Name and Address of your Doctor Warning Phone Number of your Doctor Warning Emergency Contact Name(required) Warning Emergency Contact Phone Number(required) Warning Your Weight (This is for health & safety reasons for our dental chair) Warning COVID-19 SCREENING QUESTIONS Have you tested positive for COVID 19 in the last 7 days?(required) Warning Are you waiting for a COVID-19 test or the results?(required) Warning Do you have any of the following symptoms? New continuous cough* High temperature or fever Loss of or change in sense of smell or taste? None of the above Warning *A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If you usually have a cough, it may be worse than usual. Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days? Warning MEDICAL HISTORY QUESTIONS ARE YOU CURRENTLY Receiving treatment from a doctor, hospital, clinic, or specialist?(required) Warning Taking any prescribed medicines (eg, tablets, ointments, injections or inhalers including contraceptive or hormone replacement therapy)?(required) Warning Please list all your medication (including self prescribed): (required) Warning Taking any medication to thin your blood (warfarin, heparin)?(required) Warning Taking or have taken steroids in the last two years?(required) Warning Allergic to antibiotics, medicines, food, latex, or other substances?(required) Warning Pregnant/breast feeding or had a baby in the last 12 months?(required) Warning HAVE YOU HAD Jaundice, hepatitis, liver or kidney disease?(required) Warning Heart problem, heart murmur, angina, or heart attack? (required) Warning High or low blood pressure or stroke?(required) Warning Hiatus hernia or stomach problem?(required) Warning DO YOU CURRENTLY Have arthritis or osteoporosis?(required) Warning Have a pacemaker?(required) Warning Suffer from a painful neck or back?(required) Warning Suffer from hay fever, eczema or other skin conditions?(required) Warning Suffer from bronchitis, asthma or any other chest conditions? Use an inhaler?(required) Warning Have diabetes (or does anyone in your family)?(required) Warning Have creutzfeldt-jakob disease?(required) Warning Have fainting attacks, giddiness, blackouts, epilepsy?(required) Warning Bruise easily? Or suffer from persistent bleeding following injury, tooth extraction or surgery? (required) Warning DID YOU AS A CHILD OR SINCE, HAVE Blood refused by the blood transfusion service?(required) Warning A bad reaction to general or local anaesthetic?(required) Warning Treatment that required you to be in hospital?(required) Warning SMOKING Do you smoke any tobacco products now (or did you in the past)? Please enter how many smoked per day.(required) Warning Drinking Do you regularly drink more than 7 units per week? Please give details(required) Warning DO YOU Have any other aspects concerning your health, past or present, that you think we should know about? (required) Warning DENTAL HISTORY CHECK When did you last visit a dentist and what practice was this?(required) Warning Are you currently experiencing any problems with your teeth or gums?(required) Warning Do your gums bleed?(required) Warning Are you satisfied with the appearance of your teeth and smile?(required) Warning Would you like your teeth to be whiter? (required) Warning Would you like any further information about Teeth Straightening Dental Implants Tooth Whitening Smile Makeovers Cosmic Bonding Anything else you would like to know about Warning Warning Is there any other information you would like us to know about ie special occasion coming up, wedding, graduation etc. Warning How did you hear about us? Warning Thank you Signature (Name)(required) Warning Date (YYYY-MM-DD)(required) Warning By submitting this form you are giving us consent to store your details securely at Tender Dental Care Dental Practice and giving us consent to contact you. (required) I agree Warning Warning. submit nowSubmitting form Δ
