Medical History Form Name * First Name Last Name Email Date of Birth * Home address * Telephone number - mobile/landline * Occupation How long since your last dental treatment? On a scale of 1 to 10 how nervous are you? 10 as being phobic of dentists 1. Not nervous at all. 2. 3. 4. 5. 6. 7. 8. 9. 10. Dental phobic - not able to enter a dental practice. Currently receiving treatment from a Doctor or Hospital? Also please list all illnesses and diseases that you have been diagnosed with Currently taking any prescribed medications? If yes, please list below with doseage If female, are you currently pregnant or nursing? Allergic to any medicines or substances in particular Latex? Taking any blood anti-coagulants, such as - Warfarin, Aspirin or Heparin? Reason for dental examination/home-visit - please list information below i.e. main concerns or complaints etc. * Treatment preferences - is there a certain type of treatment you or the patient would prefer to have or have in mind? Please also specify is there a certain budget for cost of treatment * Diabetic? Suffer from bronchitis, asthma or any other chest conditions? Suffer from fainting attacks, giddiness, blackouts or epilepsy? Suffer from heart problems, angina, blood pressure problems or stroke? Carry a medical warning card? Suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? Suffer from any infectious diseases? (including HIV and hepatitis) Had any other serious illness? Ever had a bad reaction to local or general anaesthetic? Do you regularly drink more than 21 units of alcohol per week? Do you smoke tobacco products now? (or have in the past) For patients who suffer with dementia or Alzheirmers - please indicate how co-operative the patient will be with opening their mouth and how they will behave during a dental examination Is there any other information the dentist might need to know about? If there is anything that you would like to discuss with the dentist, but prefer not to write down, please tick 'yes' below; Yes No I confirm the above information is correct to the best of my knowledge. I understand that any costs and treatment I need will be explained to me by the dentist. I am aware that no credit is given, and I will pay for treatment on the day of appointment. (crowns, bridges, implants, orthodontic appliances and dentures will have to be paid for before the fitting date usually on the impression taking appointment). I also understand that should I not give 1 working days’ notice for cancelling or rescheduling any appointment that I may be charged a minimum of £50.00. By signing below, you agree that you have read the fair processing notice reference below and are giving consent for us here at Clinic for Implant & Orthodontic Dentistry to process and hold your data. We will not give your information to any third party without your prior consent. All information will be held in the strictest of confidence in line with the GDPR (General Data Protection Regulation). To read our fair processing notice either go on the website http://dental-worthing.co.uk/gdpr-fair-processing-notice-for-patients, have a look in the patient information folder or ask for a copy of it. Signature * Date * Thank you! Download Medical History Form (PDF) Here