Medical History

Medical history form - to be completed before dental appointment.

Contact Form (required fields marked*)

Patient Information



Your Doctor's Surgery


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

Do you or anyone in your household or support bubble have a confirmed diagnosis of Covid-19?*


Are you or anyone in your household or support bubble waiting for a Covid 19 test result?*


Have you travelled internationally in the last 14 days?*


Have you had contact with someone with a confirmed case of Covid 19 or been in isolation with a suspected case in the last 14 days?*


Have you been contacted by NHS test & trace?*


Do you or anyone in your household or support bubble have a new continuous cough, a high temperature or a loss, or change in your normal sense of taste or smell?*


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


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

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