WOODHALL FARM DENTAL SURGERY – CONFIDENTIAL MEDICAL HISTORY

Please complete and return to the surgery by post or when you next attend

Title …………   Surname……………………………..  Forename……………………...

 Address ……………………………………………………………………………………

 ………………………………………………………………………………………………

 ………………………………………………  Postcode ………………………………….

 Telephone no:- …………………………… home ……………………….. work/mobile

 Date of Birth ……………………………….  Occupation ………………………………

 To ensure you receive appropriate care during dental treatment please complete this form carefully ensuring you answer all questions:-

 Do you have or have you ever suffered from:

Rheumatic fever ? …………………………………………………    Yes / No

 Any heart complaint including murmur ? ………………….        Yes / No

 Diabetes ? …………………………………………………………      Yes / No

 Epilepsy ? …………………………………………………………      Yes / No

 Chronic bronchitis or asthma ? …………………………………... Yes / No

 Hepatitis ? …………………………………………………………     Yes / No

 Excessive bleeding ? ………………………………………………    Yes / No

 High blood pressure ? ……………………………………………..    Yes / No

 Any other serious illness ? ………………………………………..   Yes / No

 Are you allergic to any medicines, tablets, sticking plasters etc ?           Yes / No

 Are you currently taking any medicines or tablets ? …………….            Yes / No

 Are you pregnant or mother of a child under 1 year old ? …            Yes / No

 In the past 2 years have you undergone any operations or
  been treated with steroids ? …………………………………………...            Yes / No

 Have you ever had a joint replaced ? …………………………………            Yes / No

 Please indicate or tell the dentist if you are HIV positive …………….       Yes / No

 Please indicate your average weekly consumption of alcohol  …………………..

 If you smoke, how many per week (average) ? …………………………………..

 If you have answered yes to any of the above questions please give details overleaf.  If you are not sure of any of the questions or your medical circumstances change please tell the Dentist.

 Name and Address of Doctor ……………………………………………………………………….

 Patients Signature …………………………………………………….  Date …………………………….

 Dates of  amendments (to be initialled) ……………………… / …………………… / ………………….