Confidential Medical History Form

ALBION DENTAL

7 Albion Street, Lewes, East Sussex, BN7 2ND

01273 474 749,

Confidential Medical History Form

To help us treat you safely we ask all patients the following questions about their general health. Please answer all questions with a `yes` or `no` and if necessary add any additional details. All information provided will be kept strictly confidential.

Mr/ Mrs/ Miss/Ms/ Master Please Circle

Surname: ______

Forenames:______Date of birth: ______Male / Female (please circle)

Permanent Address: ______

______Post code: ______

Home Telephone: ______Work Telephone: ______Mobile phone: ______E-Mail address: ______

How do you prefer to be contacted?: ______Occupation: ______Date of last dental treatment (if known, your previous dental practice): ______

Doctors name and address (GP): ______Doctors telephone:______

How did you hear about our dental practice?: ______

Are you currently:

• Pregnant?
• Receiving treatment from a doctor/hospital/clinic?
• Taking prescribed medicines (eg-tablets,

ointments, injections or inhalers ,including

contraceptives/ hormone replacement therapy)?

• Carrying a medical warning card?
• Taking or taken steroids in the last 2 years?

Do you suffer from:

• Allergies to any medicines (eg: penicillin), substances (eg: latex Rubber), any foods.
• Hayfever or eczema?
• Bronchitis, asthma or other chest conditions?
• Fainting attacks, giddiness, blackouts, epilepsy?
• Heart problems, angina and stroke?
• Diabetes (or anyone in the family)?
• Arthritis?
• Bruising or persistent bleeding following injury, tooth

extraction or surgery?

• Snoring (or anyone in your family)?
• Headaches/Migraines
• Anaemia
• Blood disorders:

High blood pressure/Low blood pressure

Please turn over:

Did you as a child or ever since have:

• Rheumatic fever or chorea?
• Liver disease/Jaundice/Hepatitis or kidney infection
• Any other serious illness
• Blood refused by the blood service?
• A bad reaction towards general or local anaesthetic?
• A joint replacement or any other implant?
• Heart surgery?
• Brain surgery?
• Growth hormone treatment before the mid 1980`s?
• A close relative (parents, child, grandparent, Grandchildren)

with Creutzfeldt-Jakob disease?

• Blood borne diseases i.e. Aids, HIV?

Drinking habits:

How many units of alcohol to you drink per week?______units per week

(1 unit= ½ pint of lager; Single measure of spirits;Single glass of wine)

Smoking/chewing habits:

Do you smoke any tobacco products now or in the past?______

Do you chew tobacco, pan, sutkha or supari or have you in the past?______

PLEASE give any other details which your dentist might need to know about, such as self prescribed medicines (eg aspirin)

Completed by: self…………………… parent……………………… guardian…………………………

Signature:……………………………………………………………………...... Date: …………………….