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PATIENT ASSESSMENT & MEDICAL HISTORY QUESTIONS (July 2017)

Please bring along your Hospital/Health Passport if you have one & details of exemption if you don’t have to pay for NHS charges
Mrs Miss Ms Mr Mstr
Sex M / F / Date of birth / Address / Doctor
Name
Address
First name / Surname
Contact number/s / POSTCODE / National Insurance No:
Child’s school – / Ethnicity - / NHS number:
Do you want us to share your information with a specific person? Yes / No Relative / Friend / Carer
Name - Contact information – Telephone number / email?
Do you have, or have you had: / No / Yes / give details please
Taking any medicines, drugs, pills, inhalers, suppositories or skin creams, contraceptive pill etc / Please list medication
Heart disease, surgery
Chest pains, angina, swollen ankles
Problems with blood pressure
Pacemaker, defibrillator
Bronchitis, pneumonia, pleurisy
Emphysema, chest surgery, cystic fibrosis, COPD
Other chest condition
Hepatitis B, C, HIV or had blood transfusion
Bleeding problems, abnormal bruising
Anaemia, sickle cell
Haemophilia, other bleeding disorder
Diabetes (sugar in urine) type I or II
Jaundice, liver disease
Kidney, urinary problems
Epilepsy, convulsions, fits
Indigestion, hiatus hernia, gastric reflux
Mental health condition / Details please
Learning disability, autism or special needs
Any other serious illness, condition or syndrome e.g. cancer, osteoporosis
Previous general anaesthetics for any operation, including dental treatment
If “yes”, were there any problems
Weight stones/pounds or kilograms

Are you pregnant, or think you might be?

Are you breast feeding?
Do you faint easily?
Breathlessness?
Do you drink alcohol?
Do you smoke? Chew tobacco? Vape?
Have you ever/do you take recreational drugs?

Allergy to penicillin

Asthma, eczema, hay fever
Allergic to, or had any reactions to any medicines, drugs, local anaesthetic, food, elastoplast, latex etc
Taking steroids or had any in the past year

Date ✘...... Signature ✘...... Relationship to patient ✘......

Checked Date ✘...... Dentist’s Signature ✘...... Dentist’s Name ✘......