Medical History Form Patient Details Name(required) Email(required) Gender(required) Male Female Non Binary Date of Birth(required) Home Address(required) Home Phone Number(required) Mobile Phone Number Name and Address of your Doctor Phone Number of your Doctor Emergency Contact Name(required) Emergency Contact Phone Number(required) Occupation COVID-19 SCREENING QUESTIONS Have you tested positive for COVID 19 in the last 7 days?(required) Are you waiting for a COVID-19 test or the results?(required) 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 *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? MEDICAL HISTORY QUESTIONS ARE YOU CURRENTLY Receiving treatment from a doctor, hospital, clinic, or specialist?(required) Taking any prescribed medicines (eg, tablets, ointments, injections or inhalers including contraceptive or hormone replacement therapy)?(required) Please list all your medication (including self prescribed): (required) Taking any medication to thin your blood (warfarin, heparin)?(required) Taking or have taken steroids in the last two years?(required) Allergic to antibiotics, medicines, food, latex, or other substances?(required) Pregnant/breast feeding or had a baby in the last 12 months?(required) HAVE YOU HAD Jaundice, hepatitis, liver or kidney disease?(required) Heart problem, heart murmur, angina, or heart attack? (required) High or low blood pressure or stroke?(required) Hiatus hernia or stomach problem?(required) DO YOU CURRENTLY Have arthritis or osteoporosis?(required) Have a pacemaker?(required) Suffer from a painful neck or back?(required) Suffer from hay fever, eczema or other skin conditions?(required) Suffer from bronchitis, asthma or any other chest conditions? Use an inhaler?(required) Have diabetes (or does anyone in your family)?(required) Have creutzfeldt-jakob disease?(required) Have fainting attacks, giddiness, blackouts, epilepsy?(required) Bruise easily? Or suffer from persistent bleeding following injury, tooth extraction or surgery? (required) DID YOU AS A CHILD OR SINCE, HAVE Blood refused by the blood transfusion service?(required) A bad reaction to general or local anaesthetic?(required) Treatment that required you to be in hospital?(required) SMOKING Do you smoke any tobacco products now (or did you in the past)? Please enter how many smoked per day.(required) Drinking Do you regularly drink more than 7 units per week? Please give details(required) DO YOU Have any other aspects concerning your health, past or present, that you think we should know about? (required) DENTAL HISTORY CHECK When did you last visit a dentist and what practice was this?(required) Are you currently experiencing any problems with your teeth or gums?(required) Do your gums bleed?(required) Are you satisfied with the appearance of your teeth and smile?(required) Would you like your teeth to be whiter? (required) 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 Is there any other information you would like us to know about ie special occasion coming up, wedding, graduation etc. How did you hear about us? Thank you Signature (Name)(required) Date(required) 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 submit now
