Medical History Form

If the patient is under 18 years of age, a parent or an adult guardian is required to complete this form.

If not the patient, the name of the person filling in this form.

The relationship of this person to the patient.

The patient’s regular medical doctor.

Doctor’s address and telephone number.

Does the patient have or ever had any of the following conditions?

 Heart disease Heart attack Heart murmur Congenital heart defects Rheumatic fever Artificial heart valve Mitral valve prolapse Pacemaker Chest pain High blood pressure Stroke Tuberculosis Asthma Diabetes Kidney disorders Liver disorders Hepatitis Arthritis Rheumatism Thyroid disorders Stomach ulcers Mouth ulcers Cold sores Artificial joint (hip, knee) Blood transfusion Blood disorders Epilepsy / seizures Fainting / dizzy spells Tumours / cancers Radiotherapy Chemotherapy Psychological problems Neurological problems Latex allergy Penicillin allergy Allergy to anaesthetic Sinusitis Hay fever Bruises / bleeds easily Family history of heart disease Headaches / migraines Jaw joint concerns Grinding / clenching Snoring / sleeping problems

Please tick if the patient may have or may have had the following high risk conditions:

 Creutzfeldt-Jakob Disease Hepatitis B or C AIDS / HIV

Medications that the patient is taking (please indicate name, purpose, dosage and frequency of each)

 Antibiotics Heart or Blood Pressure medication Hormone Replacement Therapy Diabetes medication The contraceptive pill (may affect blood pressure or blood clotting and antibiotics) Cancer medication or therapy Arthritis medication or creams Anti-inflammatories, e.g. Nurofen, Ibubrofen, Voltaren, Aclin Asthma medication or inhaler Pain killers, e.g. Aspirin, Panadol, Codeine Bisphosphonates, e.g. Didronel, Bonefos, Fosamax, Actonel, Pamisol Natural therapies Nicotine Replacement Therapy Other medications

Does the patient smoke?
 Yes No

Does the patient drink alcohol?
 Yes No

For Women: are you pregnant?
 Yes No

Privacy Policy - We need the information set out above in order to provide you with safe, effective and efficient dental services. You are entitled to access your information at any time and we will keep them confidential. If necessary, we may pass your information on to other health practitioners or agencies. Our complete Privacy Policy is available at reception.

Disclaimer - By signing this form, I, the patient/person responsible for the patient, have filled in this form to the best of my knowledge and ability, as honestly and accurately as possible.

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