Medical History Form - Notting Hill Dental Clinic

Personal details

Name*

Prefix First Last

Date of Birth*

Gender*

Male
Female

Home Address*

Street Address Address Line 2 City ZIP / Postal Code

Home Phone

Mobile*

Email*

Enter Email Confirm Email

Occupation*

Doctor's details

Doctor's Name*

Doctor's address*

Street Address Address Line 2 City ZIP / Postal Code

Medical history - do you have or have you had any of the following :

1. Are you receiving any medical treatment at the present time?*

Yes
No

2. Are you taking any medication at the present time?*

Yes
No

Q1: If yes, please list*

Q2: If yes, please list:*

3. Have you experienced any allergies/unusual effects with any tablets, drugs, injections or anaesthetic?*

Yes
No

Q3: If yes, please list:*

4. Are you, or have you been, under the care of a doctor/hospital during the past two years?*

Yes
No

Q4: If yes, please list:*

5. Have you ever had any of the following? If so, please tick as appropriate.

Specify hepatitis type A, B or C*

6. Do you or have you ever suffered from excessive bleeding or bruising?*

Yes
No

7. Do you smoke or drink alcohol? If so what is your weekly intake?*

Yes
No

Q6: If yes, please list:*

Q7: if yes, please list*

Tabaco	Alcohol Units

8. If applicable, are you pregnant ? If so, expected due date :*

Yes
No

9. Are you HIV positive?*

Yes
No

Q8: Date*

Dental History

1. Do you have Dental pain or a Dental problem at present?*

Yes
No

2. When did you have your last routine dental examination ?*

Consent

Consent*

Please tick to confirm the information is correct & Sign below*

Signature*

Date of Signature

Comments

This field is for validation purposes and should be left unchanged.

Patient Registration & Medical History

Personal details

Doctor's details

Medical history - do you have or have you had any of the following :

Dental History

Consent