Medical History

Home Medical History

To obtain the best and safest treatment, our dentist needs to know of any problems, which may affect your treatment. All the information listed by you is strictly confidential.

Name*
First Last
Address*
Address Line 1 Address Line 2 Town/City County Postcode
Gender*
- Male
- Female
D.O.B*
Date Format: DD slash MM slash YYYY
Email*
Home Phone
Mobile*
Work
Habits
Smoke (per day)
Chew tobacco(per day)
Alcohol(units per week)
High sugar/frequency
- Yes
- No
Lots of fizzy/acidic drinks
- Yes
- No
Recreational drugs
- Yes
- No
If "Yes" to any please explain
Warnings
Pregnant or possible pregnant
- Yes
- No
Antibiotic cover required
- Yes
- No
Bruising or persistent bleeding
- Yes
- No
Currently under treatment
- Yes
- No
Anything dentist should know
- Yes
- No
Do not recline
- Yes
- No
Steroids within 2 years
- Yes
- No
Warning card
- Yes
- No
Treatment requiring hospitalisation
- Yes
- No
If "Yes" to any please explain
Heart
Rheumatic Fever
- Yes
- No
High Blood Pressure
- Yes
- No
Heart Surgery
- Yes
- No
Pacemaker fitted
- Yes
- No
Heart Murmur
- Yes
- No
Thrombosis
- Yes
- No
Angina
- Yes
- No
Other heart conditions
- Yes
- No
If "Yes" please explain
Chest
Bronchitis
- Yes
- No
Cystic Fibrosis
- Yes
- No
Pleurisy
- Yes
- No
Asthmatic
- Yes
- No
Emphysema
- Yes
- No
Pneumonia
- Yes
- No
Chest Surgery
- Yes
- No
Other chest conditions
- Yes
- No
If "Yes" please explain
Blood
Hepatitis B
- Yes
- No
H.I.V
- Yes
- No
Abnormal Blood Test
- Yes
- No
Blood refused by transfusion svce.
- Yes
- No
Anaemia
- Yes
- No
Sickle Cell
- Yes
- No
Haemophilia
- Yes
- No
Other blood conditions
- Yes
- No
If "Yes" please explain
Medication
Details
Allergies
Penicillin
- Yes
- No
Hay-Fever
- Yes
- No
Anti Tetnus Serum
- Yes
- No
Eczema
- Yes
- No
General Anaesthetic
- Yes
- No
Local Anaesthetic
- Yes
- No
Latex Allery
- Yes
- No
Medicines
- Yes
- No
Plants
- Yes
- No
Foods
- Yes
- No
Asprin
- Yes
- No
Asprin
- Yes
- No
If "Yes" to any please explain
Other
Liver Disease
- Yes
- No
Diabetes(patient or family)
- Yes
- No
Acid Reflux or Eating Disorder
- Yes
- No
Bone or Joint Disease
- Yes
- No
Kidney Disease
- Yes
- No
Epilepsy
- Yes
- No
Hiatus Hernia
- Yes
- No
Artificial Joint
- Yes
- No
Fainting Attacks or Blackouts
- Yes
- No
Past serious or Infectious Disease
- Yes
- No
Giddiness
- Yes
- No
Cancer
- Yes
- No
If "Yes" to any please explain
COVID-19 Triage Questions
Have you tested positive for Covid-19 in the last 7 days?*
- Yes
- No
Are you waiting for Covid-19 test or the results?*
- Yes
- No
Do you have a high temperature – 37.8 C or above?*
- Yes
- No
Do you have a new persistent cough - this means coughing for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).*
- Yes
- No
Do you have a new loss of, or change in, sense of smell or taste (anosmia)?*
- Yes
- No
Do you live with someone who has either tested positive for Covid-19 or had symptoms of Covid-19 in the last 14 days? if yes, are you still in the self /household isolation period?*
- Yes
- No
Have you been notified by NHS Test and Trace in the last 14 days that you are a contact of a person who has tested positive for Covid-19 and you do not live with that person?*
- Yes
- No
If anything changes before your appointment and you answer yes to any of the Covid-19 triage questions, please contact us immediately.
Signature*
Date Of Signature*
Date Format: DD slash MM slash YYYY

19 Covingham Sq. Swindon, Wiltshire, SN3 5AA

Call Now

Treatments

Cosmetic, Whitening, Smile Makeover
Invisalign
New Patients

Information

Privacy Policy
CQC Certificate
Complaint Policy

Call Now

Contact Us

Medical History

Habits

Warnings

Heart

Chest

Blood

Medication

Allergies

Other

COVID-19 Triage Questions