HARBOUR DENTAL PRACTICE       CONFIDENTIAL MEDICAL HISTORY FORM (2007)
Title                                 Name
Date of Birth                     Sex                        Occupation
Address
Telephone Home                                                     Work
Last saw DENTIST                              Medical Practitioner

YES

NO

DETAILS

Are you under treatment from your doctor or hospital

 

 

 

Are you taking ANY tablets,   medicines, pills etc

 

 

 

Have you had steroids in the past two years

 

 

 

Are you pregnant

 

 

 

Are you allergic to any medicines or substances

 

 

 

Have you had a test for HIV

 

 

 

Have you ever had rheumatic fever

 

 

 

Have you ever had    MRSA

 

 

 

Have you or a family member had    CJD

 

 

 

Are you allergic to penicillin

 

 

 

Do you suffer from high blood pressure

 

 

 

Have you ever had angina or a heart attack

 

 

 

Have you had a heart murmur or heart surgery

 

 

 

Do you have a pacemaker

 

 

 

How much alcohol do you consume per week

 

 

……….units per week

Have you had a bad reaction to local anaesthetic

Have  you been in hospital in the last two years

 

 

 

Do you suffer from asthma or bronchitis

 

 

 

Do you smoke, if so how many a day

 

 

number per day………….

Do you suffer from epilepsy or have blackouts

 

 

 

Do you or your family have diabetes

 

 

 

Do you take anticoagulants or      warfarin

 

 

 

Do you need treatment for bleeding after extractions

 

 

 

Do you carry any warning cards

 

 

 

Are there any things that you think we need to know about your health

 

 

Completed by self / parent / guardian                                               Date
Updated                   /                          /                           /                            /                           /

Thank you for completing this, naturally all information is treated in the strictest confidence.