Medical History Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Mobile(Required)Are you happy to be contacted by mobile or text (GDPR)?(Required) Yes No Email(Required) Are you exempt from NHS charges?(Required) Yes No If YES, please do let reception know.Occupation(Required) When did you last see a dentist?(Required) Doctors Details(Required) DO YOU SUFFER FROM? If yes, please circle the condition.Allergies to any medication e.g. (penicillin) Substances e.g. (latex/ rubber or food)(Required) Yes No A heart murmur or heart problems, angina, blood pressure problems, or stroke(Required) Yes No Diabetes(Required) Yes No Fainting attacks, giddiness, blackouts, epilepsy(Required) Yes No Bronchitis, asthma, or any other chest conditions(Required) Yes No Infectious disease including HIV/AIDS(Required) Yes No Arthritis, bone, or joint disease(Required) Yes No Bruising or persistent bleeding following tooth extraction or surgery(Required) Yes No Have you ever had? If yes, please circle the condition.(Required) Rheumatic fever or chorea Liver disease Jaundice Hepatitis Kidney disease Any other serious illness?(Required) Yes No If yes, please mention(Required) Bad reaction to local or general anaesthetic(Required) Yes No Joint replacement or any other implant(Required) Yes No A pacemaker or any form of heart surgery.(Required) Yes No Are you currently? Pregnant(Required) Yes No Any other serious illness? Carrying a warning card(Required) Yes No Taking any medication? If yes, please hand in your repeated prescription.(Required) Yes No Have you been prescribed bisphosphonate treatment either tablet or injection?(Required) Yes No Do you smoke any tobacco products?(Required) Yes No If yes, how many per day.(Required) Do you chew tobacco pan, use gutkha or supari?(Required) Yes No SMOKERS – are you interested in receiving smoking cessation advice?(Required) Yes No Do you drink alcohol?(Required) Yes No If yes, how many units per week(Required) Glass of wine 125ml-1.7 units 175ml – 2.3 units Can of beer 440ml – 1.8 units Pint 568ml 2.3 units Do you consider yourself to have any disability?(Required) Yes No In case of emergency who would you like us to contact?(Required) Yes No Signed by(Required) Patient Parent Guardian Other Other (Please State)(Required) Signature(Required)Date(Required) MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
