Medical History Form Medical History FormStep 1Step 2Step 3Step 4Patient DetailsTitle- Select -MrMrsMissMsMasterDrPrefer not to sayFirst NameLast NameAddressAddress Line 1Town/Village/CityCountyPost CodeEmailPhone no.Gender- Select -MaleFemaleOtherDate of BirthOccupationName and Address of your DoctorPhone Number of your DoctorEmergency Contact NameEmergency Contact Phone NumberYour WeightPreviousNextMedical History QuestionsAre you receiving treatment from a doctor, hospital, clinic, or specialist? Yes NoPlease provide details of the treatment you are receivingAre you taking any prescribed medicines (eg, tablets, ointments, injections or inhalers including contraceptive or hormone replacement therapy)? Yes NoPlease list all your medication (including self prescribed):Have you ever taken bone-strengthening drugs (e.g., bisphosphonates)? Yes NoHave you ever had a bad reaction to local or general anaesthetic? Yes NoAre you taking or have you taken steroids in the last two years? Yes NoAre you allergic to Penicillin or any other antibiotics, medicines, specific foods, preservatives, rubber, latex, or other substances? Yes NoList all of your allergiesAre you pregnant, breast feeding or have you had a baby in the last 12 months? Yes NoHave you had any of the following conditions? (select all that apply) Jaundice, hepatitis, liver or kidney disease Heart problem, heart murmur, valve issues, angina, or heart attack High or low blood pressure or stroke Hiatus hernia or stomach problem Stroke, TIA, or blood clotProvide details of the condition/s you had in the box belowDo you currently have any of the following conditions? (select all that apply) Have arthritis or osteoporosis Have a pacemaker Suffer from a painful neck or back Suffer from hay fever, eczema or other skin conditions Suffer from bronchitis, asthma or any other chest conditions? Use an inhaler? Have diabetes (or does anyone in your family) If yes, please state: Type 1 / Type 2 Have creutzfeldt-jakob disease Have fainting attacks, giddiness, blackouts, epilepsy Bruise easily? Or suffer from persistent bleeding following injury, tooth extraction or surgery Infectious diseases (e.g., HIV, Hepatitis B/C) Bleed excessively if cut, or take blood thinners (e.g., Warfarin, Aspirin)?Provide details of the condition/s you have in the box belowDid you as a child, or since, have? (select all that apply) Blood refused by the blood transfusion service A bad reaction to general or local anaesthetic Treatment that required you to be in hospitalProvide details in the box belowDo you smoke tobacco or use e-cigarettes / vapes now (or did you in the past)? I'm currently an e-cigarettes / vapes user I used to be an e-cigarettes / vapes user I am a smoker I am an ex-smoker I have never smokedPlease enter how many smoked per day.Do you regularly drink more than 7 units per week? Please give detailsDo you have any other aspects concerning your health, past or present, that you think we should know about?PreviousNextDental History QuestionsWhen did you last visit a dentist and what practice was this?Are you currently experiencing any problems with your teeth or gums? Yes NoProvide details of the problem you are currently experiencing with your teeth or gumsDo your gums bleed? Yes NoAre you satisfied with the appearance of your teeth and smile? Yes NoWould you like your teeth to be whiter? Yes NoWould you like any further information about Teeth Straightening (e.g, clear aligners) Dental Implants Teeth Whitening or cosmetic smile enhancements Cosmic Bonding Something elseWould you like your teeth to be whiter? Yes NoWhat would you like further information about?How did you hear about us?Is there any other information you would like us to know about? ie special occasion coming up, wedding, graduation etc.PreviousNextDeclaration & Sign-off I confirm that the information provided above is correct to the best of my knowledge. I will inform the dentist if any changes to my medical status occur.Signature (Name)Select today's date By submitting this form you are giving us consent to store your details securely at Tender Dental Care Dental Practice and give us consent to contact you. Previous Submit Form
