Medical History Form Please submit this medical history form before attending your appointment. New Patient Medical Questionnaire New Patient Medical Questionnaire Name * First Name Last Name Email * Date of Birth (DD/MM/YYY) * Contact Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you currently receiving treatment from a doctor, hospital or clinic? * Yes No Are you currently taking any prescribed medicines (e.g. tablets, ointments or inhalers, including contraceptives and hormone replacement therapy)? * Yes No Are you pregnant? * Yes No N/A Do you suffer from allergies to any medicines (e.g. penicillin), substances (e.g. latex/rubber) or foods? * Yes No Do you suffer from * Hay fever Eczema Bronchitis Asthma other chest conditions None of the above Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? * Yes No Do you suffer from heart problems, angina, blood pressure problems, or stroke? * Yes No Are you diabetic (or is anyone in your family)? * Yes No Family member with Diabetes Do you suffer from arthritis? * Yes No Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? * Yes No Do you suffer from any infections/diseases (including HIV and hepatitis)? * Yes No Have you ever had: * Rheumatic fever or chorea Liver disease (e.g. jaundice, hepatitis) or kidney disease Any other serious illness None of the above Have you ever had blood refused by the Blood Transfusion Service? * Yes No Have you ever had a bad reaction to general or local anaesthetic? * Yes No Have you ever had treatment that required you to be in hospital? * Yes No Have you ever one of the following surgeries: * Heart Surgery Brain Surgery N/A Do you have any close relatives (parent, sibling, child, grandparent or grandchild) with creutzfeldt jakob disease? * Yes No Do you regularly drink more than 21 units of alcohol per week? * Yes No Do you smoke any tobacco products now (or did you in the past)? * Yes No Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin)? Yes No Additional Information, please include any medication you are currently taking Have you experienced any of the following: * Felt hot/feverish recently (in the last 14 days)? Any shortness of breath or other difficulties breathing? Persistent cough? Flu-like symptoms / gastrointestinal upset / headache / fatigue? Recent change in taste or smell? None of the above Have you been in contact with any confirmed/suspected COVID-19 positive patients? * Yes No Have you previously been diagnosed with COVID or suspect you may have had COVID? * Yes No Unsure Would you be interested in COVID antibody testing? * Yes No Name and information of your GP How long has it been since your last visit to the dentist? Less than 6 months 7 - 12 months Over 12 months Cannot remember How did you find out about us? Recommended by current patient Referred by dentist/hygienist Walked past practice Google/other search engine Facebook/Instagram Other If other, please specify Thank you!
