Confidential Medical History Form Order Number Please complete this form prior to your dental appointment. For confidentiality, please do not enter your full name or full postcode - only insert your initials and the last three characters of your postcode as requested. Initials Only (Not Full Name) * Date of birth * Last three characters of postcode * Are you currently receiving any medical treatment? * Yes No Have you been in hospital in the past two years? * Yes No Do you have a medical prosthesis? (e.g. hip replacement, prosthetic heart valve) * Yes No Do you carry a medical warning card? * Yes No Are you pregnant or breastfeeding? * Yes No Not Applicable Do you have any allergies? (e.g. penicillin, latex, plasters, aspirin) * Yes No Please provide details if you answered Do you take any prescription medication? If so, please write a list of your medication Do you currently, or have you ever taken, any of the following; Steroid medication? * Yes No Blood thinning medication? (such as warfarin, apixaban, rivaroxaban) * Yes No Bisphosphonate medication (such as alendronic acid)? * Yes No Do you suffer from, or have you ever suffered from: Asthma / Bronchitis * Yes No Fainting Attacks / Epilepsy * Yes No Heart Problems / Angina * Yes No Bone / Joint Problems * Yes No Excessive Bleeding * Yes No Liver Disease * Yes No Hepatitis * Yes No Kidney Disease * Yes No Blood Pressure * Yes No Stomach Ulcers * Yes No HIV / AIDS * Yes No Diabetes * Yes No Any other details which your dentist might need to know? Do you drink alcohol? * Yes No If so, how many units a week on average? (A unit is half a pint of lager, a single measure of spirit, a single glass of wine/aperitif) Do you smoke or chew tobacco? * Yes No If so how many times a day? Would you like advice from your dentist about quitting? * Yes No Not Applicable
