Medical History Form – Thorpe Dental Group, York

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BISHOPTHORPE: 01904 703427

WOODTHORPE: 01904 706795

COPMANTHORPE: 01904 706291

ABOUT
IMPLANTS
- TEETH-IN-A-DAY
TREATMENTS
AESTHETICS
FAQS
CONTACT

BOOK NOW

ABOUT
IMPLANTS
- TEETH-IN-A-DAY
TREATMENTS
AESTHETICS
FAQS
CONTACT

Confidential Medical History Form

Do not use the BACK button while completing the form as you may lose your answers.
Use the PREVIOUS button if you need to go back a stage to make a change. All fields required.

PERSONAL INFORMATION

Title

First name

Last name

Gender

Male Female

Date of birth

Occupation

Home address

Email

Home telephone

Work telephone

Mobile number

Name and address of your doctor

When did you last see a dentist?

Preferred practice

Woodthorpe Bishopthorpe Copmanthorpe

MEDICAL INFORMATION

Are you currently receiving treatment from a doctor, hospital, clinic or specialist?

Yes No

Are you taking any medicines, tablets, drugs, injections or using any creams, ointments or inhalers? (Prescribed or self prescribed)

Yes No

Do you carry a warning card/wear a ‘Medicalert’ pendant?

Yes No

Do you have any allergies to medicines, foods or materials?
(Including latex, rubber, sticking plasters, penicillin, hay fever, eczema)

Yes No

Do you suffer from hay fever or eczema?

Yes No

Do you suffer from bronchitis, asthma or any other chest condition?

Yes No

Do you have fainting attacks, giddiness, blackouts or epilepsy?
If yes, when was the last episode?

Yes No

Do you suffer from heart problems, angina, blood pressure problem, or stroke? Have you ever had ‘Infective Endocarditis’?

Yes No

Do you or a family member have diabetes?

Yes No

Do you have arthritis? What joint(s) are affected?

Yes No

Do you or a family member bruise easily or suffer persistent bleeding following a tooth extraction or injury?

Yes No

Have you or another family member have any infectious disease including HIV and hepatitis?

Yes No

Have you ever had rheumatic fever, T.B. (Tuberculosis) or chorea (St. Vitus Dance)?

Yes No

Have you ever had jaundice, liver disease or kidney disease?

Yes No

Have you ever had any other serious illness?

Yes No

Have you ever had your blood refused by the Blood Transfusion Service?

Yes No

Have you ever had a bad reaction to local or general anaesthesia?

Yes No

Have you ever had a joint replacement or other implant?

Yes No

Have you ever been admitted to hospital, or had an operation?
(If yes, when and what for?)

Yes No

Do you or a family member have vCJD (viral Creutzfeldt-Jakob Disease)?

Yes No

Do you drink alcohol? If yes, how many pints, glasses of wine etc per week?

Yes No

Do you smoke any tobacco products now, or did you in the past?
If yes, how many per day?

Yes No

Do you chew tobacco, pan, betel quid (areca nut) use gutkha or supari now or in the past? If yes, how often?

Yes No

Do you think there are any other aspects, concerning your health that your dentist should know about? (Including self-prescribed medicines, e.g. aspirin)

Yes No

Are you pregnant or a nursing mother?
(Please tick yes if there is a possibility of pregnancy)

Yes No

Do you suffer from cold sores?

Yes No

Have you been abroad in the last few years to a country where you needed inoculations before your visit or treatment as a result of the visit?

Yes No

Have you ever received growth hormone treatment?

Yes No

Do you have any stomach or other gastro-intestinal problems (e.g. Crohns’s, ulcers)?

Yes No

Have you ever received an organ or blood transfusion?

Yes No

Have you taken steroids in the last 2 years?

Yes No

Additional information (optional)

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