Medical History Questionnaire
To provide the best and safest treatment, your dentist needs to know of any problems which may affect your treatment.
Please leave as unanswered questions that are not relevant to your medical history.
Email address *
Name *
Your answer
Date Of Birth *
MM
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DD
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YYYY
Sex
Address *
Your answer
Postcode *
Your answer
Phone number
Your answer
Are you currently pregnant? *
Your answer
Are you currently receiving treatment from a doctor, hospital or clinic? *
Your answer
Are you currently taking any prescribed medicines (eg tablets, ointments or inhalers, including contraceptives and hormone replacement therapy)? *
Your answer
Are you carrying a medical warning card? *
Your answer
Do you suffer from allergies to any medicines (eg penicillin), substances (eg latex/rubber) or foods? *
Your answer
Do you suffer from hay fever or eczema? *
Your answer
Do you suffer from bronchitis, asthma or other chest conditions? *
Your answer
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? *
Your answer
Do you suffer from heart problems, angina, blood pressure problems, or stroke? *
Your answer
Are you diabetic (or is anyone in your family)? *
Your answer
Do you suffer from arthritis? *
Your answer
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? *
Your answer
Do you suffer from any infections diseases (including HIV and hepatitis)? *
Your answer
Have you ever had rheumatic fever or chorea? *
Your answer
Have you ever had liver disease (eg jaundice, hepatitis) or kidney disease? *
Your answer
Have you ever had any other serious illness? *
Your answer
Have you ever had blood refused by the Blood Transfusion Service? *
Your answer
Have you ever had a bad reaction to general or local anaesthetic? *
Your answer
Have you ever had a joint replacement or other implant? *
Your answer
Have you ever had treatment that required you to be in hospital? *
Your answer
Have you ever had heart surgery? *
Your answer
Have you ever had brain surgery? *
Your answer
Did you receive growth hormone treatment before the mid 1980's? *
Your answer
Do you have any close relatives (parent, sibling, child, grandparent or grandchild) with creutzfeldt jakob disease? *
Your answer
Do you regularly drink more than 14 units of alcohol per week? *
Your answer
Do you smoke any tobacco products now (or did you in the past)? *
Your answer
Do you smoke any tobacco products now (or did you in the past)? *
Your answer
Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)? Is there any other information which your dentist might need to know about, such as self-prescribed medicines (eg aspirin)? *
Your answer
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