Medical History Form - Elmfield House Dental Practice

Patient Title

Patient Name *

First

Last

Patient Date of Birth

Patient Home Phone Number *

Patient Work Phone Number *

Patient Mobile Phone Number *

Patient Email *

Patient Address

Patient Postcode

How Do You Prefer To Be Contacted

Home Telephone
Mobile Telephone
Work Telephone
Email

Please can you tick the relevant boxes to confirm how you would like to be contacted and that you consent to us using these details to contact you. (Please note that e-mails sent and received from unsecured e mail accounts may be accessible by third parties.)

Contact Consent

I give my consent

We will only use the above information in order to remain in communication with you, remind you about appointment times, when dental check-ups and hygienist visits are due and for invoicing and payment purposes. We will not share any personal information with third parties without your prior consent and this will only be in relation to specific medical/dental healthcare pathways. We will never share your personal information for the purposes of advertising or marketing. Our data protection policies are available to view here. Please tick the consent box above if you consent to our use of your personal data as outline above:

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist at present?

YES
NO

If YES please give treatment details

Are you allergic to any medicines, foods or materials? (please specify) Do you suffer from hayfever or eczema?

YES
NO

If YES please give allergy details

Have you had a bad reaction to a local anaesthetic or any other material in the dental setting?

YES
NO

If YES please give reaction details

Do you currently smoke?

YES
NO

If yes, How long have you smoked for? How much do you smoke per day? What do you smoke e.g Cigarettes, Cigars, Vape?

Have you smoked in the past?

YES
NO

If yes, how long did you smoke for, when did you stop smoking and what did you smoke?

Do you drink Alcohol?

YES
NO

If yes, approximately how many units per day?

Have you suffered from or do you currently suffer from any infectious disease e.g Viral Hepatitis, HIV, COVID-19?

YES
NO

If YES please give details

Do you have or have you had a heart murmur, a heart valve replacement, rheumatic fever and/or infective endocarditis?

YES
NO

If YES please give details

Have you been advised that you need to take antibiotics prior to dental treatment?

YES
NO

If YES please give details e.g. By whom? Why? Which antibiotic have you been advised to take?

Do you suffer from heart disease, angina, high blood pressure, irregular heartbeat?

YES
NO

If YES please give heart disease details

Have you had a heart attack in the past?

YES
NO

When? What treatment did you receive? Do you wear a pacemaker?

Do you have an increased risk of bleeding and/or bruising?

YES
NO

If YES please give details. Are you taking any medication that might affect your clotting? e.g Warfarin, Apixoban, Clopidogrel, Aspirin

Have you in the past or do you currently suffer from Osteoporosis?

YES
NO

If YES please give details. Are you currently taking or have you previously taken any medication for it? e.g Alendronate, Zoledronic acid, Denosumab, HRT

Do you suffer from Diabetes?

YES
NO

If YES please give details. Do you take any medication to manage it (please give details) e.g Insulin, Metformin How well controlled is your diabetes?

Have you had or are you currently having treatment for cancer?

YES
NO

If YES please give details. What type of cancer are/were you affected by? Are you receiving/did you receive Radiotherapy, Chemotherapy or both?

Have you had or do you have jaundice, Liver disease (hepatitis, cirrhosis), or Kidney disease?

YES
NO

If YES please give liver/kidney disease details

Do you suffer from bronchitis, asthma, difficulty breathing or any other chest condition?

YES
NO

If YES please give details. Do you use an inhaler(s)? (please specify)

Do you suffer from impaired hearing?

YES
NO

If YES please give details. Do you wear hearing aid(s)?

Are you pregnant?

YES
NO

If so, when is your due date?

Are you breastfeeding?

YES
NO

Are you using an oral contraceptive pill?

YES
NO

If YES please give details.

Have you had or do you suffer from fainting attacks, giddiness, blackouts or epilepsy?

YES
NO

If YES please give details, when did you last suffer with a faint/fit/blackout?

Are there any other aspects concerning your general medical health that we should know about?

YES
NO

If YES please give details.

Please provide a comprehensive list of all medications that you are currently taking.

Include dosage and daily frequency

Provide a list of vitamins, dietary supplements and/or herbal remedies

GP Name *

GP Telephone Number

GP Address

Emergency Contact Name *

Emergency Contact Telephone Number

Relationship to patient

Patient Information & Medical History Form

Restorative Dentistry & Dental Implantology