Confidential Medical History Name* Mr.Mrs.MissMs.Dr. Prefix Surname First Date of Birth DD MM YYYY Address Street Address City State / Province / Region ZIP / Postal Code Email* Home PhoneMobile*Contact Preference Mobile/SMS Email Home phone Parent or GuardianHow did you hear of us?Name of DoctorPractice namePractice phoneEmergency ContactEmergency Contact PhoneRelationshipHeart Rheumatic Fever Heart Murmur High Blood Pressure Angina Heart Surgery Thrombosis Pacemaker Fitted Other Heart condition DetailsBlood Hepatitis B Anaemia H.I.V. Sickle Cell Abnormal Blood Test Result Blood refused by transfusion service Other Blood condition DetailsAllergies / Reactions Penicillin Eczema Aspirin Latex Anti-Tetanus Serum Plants Medicines Foods Reaction to General Anaesthetic Hay Fever Reaction to Local Anaesthetic Other Allergy DetailsChest COPD Asthma Other Chest Condition DetailsWarnings Pregnant or possibly pregnant Problem being reclined Antibiotic Cover required Steroids in last 2 years Warning Card/Bracelet Anything else your dentist should know Bruising or persistent bleeding after injury, surgery or tooth extraction Currently under treatment of a doctor, hospital or clinic Any other treatment that required you to be hospitalised DetailsOther Liver Disease (e.g. jaundice) Kidney Disease Diabetes / Family with Diabetes Epilepsy Acid Reflux or Eating disorder Bone or Joint disease Cancer Artificial Joint Fainting Attacks or Blackouts Giddiness - Vertigo DetailsMedicationList and state doses for any prescribed medicines, tablets, ointments, injections or inhalers (inc. contraceptives and HRT) you are taking:Habits Smoke tobacco products (Per day) High sugar / Frequency Fizzy/acidic/sugary drinks DetailsConfidential Oral Health SurveyWhat is the purpose of your visit?Who was your previous dentist?Please tell us about your oral health. Tick any of the statements below that apply to you.Appearance I feel self-conscious when I smile. I am dissatisfied with the appearance of my teeth. I have whitened (bleached) my teeth in the past. I have irregularly positioned (crooked or spaced) teeth that I dislike. I have chips or gaps in my teeth that worry me. I have missing teeth that concern me. Gum and Bone My gums appear red and swollen, or bleed and are painful when brushed or flossed. I have been treated for gum disease or been told I have lost bone around my teeth. I have noticed an unpleasant taste or odour in my mouth. I have noticed my gums have started receding. I have noticed my teeth are starting to become loose and I have difficulty chewing hard foods. There is a history or periodontal (gum) disease in my family. Bite and Jaw Joint I have problems with my jaw joint (pain, sounds, limited opening, locking). I have problems chewing gum. I have problems chewing hard foods. My teeth have changed (become shorter, thinner, warn) in the last 5 years. I have more than one bite position and squeeze to make my teeth fit together. I bite my nails or cheek, use teeth to hold objects, or have other oral habits. I clench my teeth in the daytime and they become sore. I have problems sleeping or wake with an awareness of my teeth. I have/do wear a bite appliance at night to protect my teeth. Tooth Structure I have had cavities in the last 3 years. I have dry mouth or have difficulty swallowing food. I noticed holes (pitting, craters) on the biting surface of my teeth. My teeth are sensitive to hot, cold, biting, sweets and I sometimes avoid brushing parts of my mouth. I snack between meals. I have sugar in my tea or coffee. I drink fruit juice or fizzy drinks between meals. I have grooves or notches on my teeth near the gum line. I have had broken/chipped teeth, or had a toothache or cracked filling. I frequently get food caught between my teeth. If you could change your smile, what would you most like to change? I would like my dentist to send me information relating to the answers I have given. I would like to be contacted about important notifications I would like to receive practice newsletters I would like to receive information about products & service or promotions. Please note that payment is required at the time of treatment. All cost in relation to collection of overdue accounts will be added to your account. Appointments not kept, failed, or cancelled without 48 hours’ notice may incur a charge. CAPTCHA
