Medical History Form

Patient Details

COVID-19 SCREENING QUESTIONS

*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.

MEDICAL HISTORY QUESTIONS

ARE YOU CURRENTLY

HAVE YOU HAD

DO YOU CURRENTLY

DID YOU AS A CHILD OR SINCE, HAVE

SMOKING

Drinking

DO YOU

DENTAL HISTORY CHECK

Thank you