Confidential Medical History Form Do not use the BACK button while completing the form as you may lose your answers. Use the PREVIOUS button if you need to go back a stage to make a change. All fields required. PERSONAL INFORMATION Title Select… Mr Mrs Miss Ms First name Last name Gender Male Female Date of birth Occupation Home address Email Home telephone Work telephone Mobile number Name and address of your doctor When did you last see a dentist? Select… Less than one month 1-3 months 6 months 1 year More than a year Preferred practice Woodthorpe Bishopthorpe Copmanthorpe MEDICAL INFORMATION Are you currently receiving treatment from a doctor, hospital, clinic or specialist? Yes No Are you taking any medicines, tablets, drugs, injections or using any creams, ointments or inhalers? (Prescribed or self prescribed) Yes No Do you carry a warning card/wear a ‘Medicalert’ pendant? Yes No Do you have any allergies to medicines, foods or materials? (Including latex, rubber, sticking plasters, penicillin, hay fever, eczema) Yes No Do you suffer from hay fever or eczema? Yes No Do you suffer from bronchitis, asthma or any other chest condition? Yes No Do you have fainting attacks, giddiness, blackouts or epilepsy? If yes, when was the last episode? Yes No Do you suffer from heart problems, angina, blood pressure problem, or stroke? Have you ever had ‘Infective Endocarditis’? Yes No Do you or a family member have diabetes? Yes No Do you have arthritis? What joint(s) are affected? Yes No Do you or a family member bruise easily or suffer persistent bleeding following a tooth extraction or injury? Yes No Have you or another family member have any infectious disease including HIV and hepatitis? Yes No Have you ever had rheumatic fever, T.B. (Tuberculosis) or chorea (St. Vitus Dance)? Yes No Have you ever had jaundice, liver disease or kidney disease? Yes No Have you ever had any other serious illness? Yes No Have you ever had your blood refused by the Blood Transfusion Service? Yes No Have you ever had a bad reaction to local or general anaesthesia? Yes No Have you ever had a joint replacement or other implant? Yes No Have you ever been admitted to hospital, or had an operation? (If yes, when and what for?) Yes No Do you or a family member have vCJD (viral Creutzfeldt-Jakob Disease)? Yes No Do you drink alcohol? If yes, how many pints, glasses of wine etc per week? Yes No Do you smoke any tobacco products now, or did you in the past? If yes, how many per day? Yes No Do you chew tobacco, pan, betel quid (areca nut) use gutkha or supari now or in the past? If yes, how often? Yes No Do you think there are any other aspects, concerning your health that your dentist should know about? (Including self-prescribed medicines, e.g. aspirin) Yes No Are you pregnant or a nursing mother? (Please tick yes if there is a possibility of pregnancy) Yes No Do you suffer from cold sores? Yes No Have you been abroad in the last few years to a country where you needed inoculations before your visit or treatment as a result of the visit? Yes No Have you ever received growth hormone treatment? Yes No Do you have any stomach or other gastro-intestinal problems (e.g. Crohns’s, ulcers)? Yes No Have you ever received an organ or blood transfusion? Yes No Have you taken steroids in the last 2 years? Yes No Additional information (optional) Acceptance I agree to be contacted by Thorpe Dental Group via email/phone/text as outlined in the Privacy Policy. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Send Can we help you?Give us a call or drop us a line today