Confidential Medical History

CONFIDENTIAL MEDICAL HISTORY

TITLE: -______NAME:-______DATE OF BIRTH:-______

ADDRESS:-______

TELEPHONE NUMBER:-HOME______WORK______MOBILE______

EMAIL ADDRESS______OCCUPATION______

Doctors Name and Address______

Contact in case of emergency NAME AND RELATIONSHIP TO YOU______

TELEPHONE NUMBER______

ARE YOU: / YES / NO / DETAILS
Receiving treatment from a doctor or clinic?
Taking any prescribed medicines?
Carrying a medical Warning Card?
Pregnant or possibly pregnant?
Taking or have taken steroids in the past 2 years?
Have you had Bisphosphonates by infusion or tablets?
Allergic to anything - substances, medicines or materials e.g. antibiotics or latex
HAVE YOU EVER HAD: / YES / NO / DETAILS
Bronchitis, asthma or other chest condition?
Fainting attacks, giddiness, or blackouts?
Epilepsy?
Heart problems, heart murmur, angina, blood pressure problems?
A stroke?
DO YOU HAVE:- / YES / NO / DETAILS
Diabetes?
Arthritis or other bone or joint disease?
A joint replacement or other implant?
A pace maker?
HAVE YOU: / YES / NO / DETAILS
Had bruising or persistent bleeding following injury, tooth extraction or surgery?
Had Jaundice, liver, kidney disease or hepatitis?
Suffered from any infectious disease (including HIV)?
A close relative with Creutzfold Jakob Disease?
HAVE YOU EVER HAD: / YES / NO / DETAILS
Blood refused by the blood Transfusion Service?
A Bad reaction to general or local anaesthetic?
Treatment that required you to be in hospital?
Heart Surgery?
DO YOU: / YES / NO / DETAILS
Smoke any tobacco? If yes approximately how many a day?
( or in the past)
Chew Tobacco, pan, use guttkha or supari now? ( or in the past)
Drink Alcohol, if yes approximately how many units? ( a unit is half pint of lager, a single measure of spirts or a small glass of wine)
Please give any other details which your dentist may need to know about, such as self-prescribed medicines (e.g. aspirin) or treatments or medicines that you prefer not to have for religious or personal reasons or have any disabilities?
Signed by: Self/ Parent/Guardian Date

Medical update: Please check the health information is still correct and indicate any changes

Signature:
Date: / Signature:
Date: / Signature:
Date: / Signature:
Date:
Changes: / Changes: / Changes: / Changes:

NEW PATIENT QUESTIONAIRRE- PREVIOUS DENTAL HISTORY

Completing this questionnaire helps us understand your dental needs. You can discuss any points you are not sure about at your dental appointment.

Name

Where did you hear about Tudor House Dental Practice?

Date of last dental Examination?

Have you had dental x-rays taken recently?

Have you any concerns about your dental care in the past?

Are your teeth sensitive?

Have you seen a dental Hygienist for treatment?

Have you any problems with loose teeth or bleeding gums?

Is there any specific dental issue you would like to discuss at your first visit?

YES / NO
Are you happy for us to contact your previous dentist for X-rays if applicable?
During Future treatment we may need to correspond with Medical Specialists. Are you happy for this information to be sent by email?
In the interest of patient care, do you give Tudor House Dental Practice permission to discuss your treatment with other health professionals?

Signature ______Date______

Tudor House Dental Practice, 64 the Street, Ashtead, Surrey KT21 1AW

Telephone: 01372 272357