Telephone
Medical History

Medical history form - to be completed before dental appointment.

Contact Form (required fields marked*)

Patient Information






*



*

Your Doctor's Surgery




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.Please tick the consent box below if you consent to our use of your personal data as outline above:


Coronavirus Screening

Have you been diagnosed with the coronavirus?*

   

Have you been in contact with someone who has a confirmed case of coronavirus?*

   

Are you or your household self-isolating?*

   

Do you or have you had a temperature of 37.8 degrees C or above in the last 14 days?*

   

Do you or have you had a dry, persistent cough in the last 14 days?*

   

Have you noticed a loss of smell and/or taste in the last 14 days?*

   

Are you in the shielded patient group?*

   


CONFIDENTIAL MEDICAL HISTORY FORM

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

   


Are you taking any medicines, tablets, drugs or injections or using any creams, ointments or inhalers?*

   


Are you taking, or have you taken, steroids in the last 2 years?*

   


Are you allergic to penicillin?*

   


Are you allergic to any medicines, foods or materials?*

   


Are you pregnant or a nursing mother?*

   

Are you HIV positive?*

   

Have you had infective endocarditis, rheumatic fever or chorea?*

   

Have you had heart surgery?*

   

Do you have a pacemaker or ICD?*

   

Have you had jaundice, liver or kidney disease or hepatitis? *

   

Have you ever had a heart murmur, heart problem, angina or high blood pressure?*

   

Have you ever had your blood refused by the Blood Transfusion Service?*

   

Have you ever had a bad reaction to a local or general anaesthetic?*

   


Have you ever been admitted to hospital?*

   


Do you have arthritis?*

   


Do you suffer from hay fever or eczema?*

   


Do you suffer from bronchitis, asthma or other chest condition?*

   


Do you have fainting attacks, giddiness, blackouts or epilepsy?*

   


Do you have diabetes or does anyone in your family?*

   


Do you bruise easily or suffer persistent bleeding following a tooth extraction or injury or does anyone in your family?*

   

Do you carry a medical warning card?*

   

Do you think there are any other aspects, concerning your health, that your dentist should know about? eg cancer*

   

Do you smoke/chew tobacco products? Or have you ever?*

   

If you drink, what is your average weekly consumption?*

   

Do you, or a close relative, have CJD?*

   

Have you had growth hormone treatment?*

   

Emergency Contact details




Confirmation

Leaflet Links (PDF documents - open in a new window)

Please confirm you have downloaded and read the information leaflet/s that you have been requested to




Please Tick The Captcha Box Below Before Submitting - Thank You!

required fields marked *
Powered by dB Masters Multimedia FormM@iler

More Information for Our Dental Patients


© Woodcock Lane Dental Care 2011 Site Last Updated Feb 2019
Dental Practice Marketing and Dental Website Design by Dental Media