Medical History Form

Do you have or have you ever had any of the following?

Rheumatic fever / congenital heart defect / bacterial endocarditis

Heart problems / angina / arrhythmia / heart attack

Circulatory problems / high blood pressure / stroke

Artificial prostheses (such as a heart valve, pacemaker, implantable defibrillator)

Breathing difficulties / asthma / emphysema / bronchitis / pneumonia

A history of bleeding problems or blood disorders in the family e.g. haemophilia or do you bruise easily?

Diabetes controlled by insulin (Type I) or oral medication (Type II)

Fainting attacks / epilepsy / fits

Liver or gall bladder disease including hepatitis / cirrhosis / jaundice

Endocrine / thyroid or hormonal imbalance

Headaches / migraines / jaw pain

Taking Bisphosphonates

None of the above

Are you a current smoker or do you currently use other tobacco products?

No

Yes

How many units of alcohol do you drink per week?,e.g 2 units for a large glass of wine or a pint. ?

None

1-10 units

11-20 units

over 20 units

Any change in your medical history since your last visit?

No

Yes

Please provide details:

Are you currently under medical treatment?

No

Yes

Are you pregnant?

No

Yes

Are you currently breastfeeding?

No

Yes

Do you have any physical or mental disability that may impair your ability to understand or consent to care?

No

Yes

Allergies to any of the following (please tick all that apply):

I have no known allergies

Drugs or medicines such as penicillin

Anaesthetics

Contact allergy e.g latex, metals

Food allergy or intolerance

Other

Please Provide Details

Are you a carrier of any of the following blood-borne viruses: HIV, Hepatitis B, Hepatitis C?

No

Yes

Medication name

Dosage

Number of times a day

Taken since

Medication name

Dosage

Number of times a day

Taken since

Medication name

Dosage

Number of times a day

Taken since

Medication name

Dosage

Number of times a day

Taken since

Please add anything else you feel may be of medical importance

Are you Happy with your smile?

No

Yes

Would you like your teeth to look whiter or brighter?

No

Yes

Are your teeth sensitive?

No

Yes

Do you feel your teeth are crowded?

No

Yes

Are you concerned you may have bad breath?

No

Yes

Do your gums bleed when you're brushing or flossing?

No

Yes

Do you clench or grind your teeth?

No

Yes

Emergency visits - which of the following requires urgent attention?

Dental pain unresponsive to painkillers

Swelling or infection

Prolonged bleeding after extraction / surgery

Recent breakage or trauma

Do you have any new dental needs?

Consent for use of clinical images

I consent to all images being used anonymously

I do not consent to any images being used outside the purposes of clinical care at Thurloe Street.

Please note that answering no will mean we will not be able to accept you as a patient

No

Yes

Signature Date

Signature (Enter Your Name)

Advanced Dentistry

Skin Clinic

020 7584 5551

Medical History Form

Confidential Medical History

Personal details and contact information

Dental Questionnaire

GDPR and consent

Please read carefully and indicate consent as appropriate

Consent for use of all clinical data held by Thurloe Street Dental: