Personal Dental Assessment

All patients must complete this medical history…you can do this now in advance or alternatively you can complete it on the day of your appointment at the practice but please arrive 10 minutes prior to your appointment time in order to do so.

All information is confidential and will not be shared with any third party.

Full Name
Date of birth
Address
Home Phone
Work Phone
Mobile
Email
Occupation
Work Address
PPS No

Which of the following statements best describes your feelings about visiting the dentist?

I feel relaxed

I feel a little anxious

I feel very nervous

If you could alter your smile what would you most like to change?

When did you last visit your dentist?

Confidential Medical History

Some medical conditions and medicines used to treat them can affect dental treatment. Please read the following and answer the questions carefully. Thank you.

	Yes	No	Further details
ARE YOU?
1. Attending or receiving treatment from a doctor, hospital clinic or specialist?
2. Taking ANY pills, tablets or medicines from your doctor?
3. Taking or have taken steroids in the last 2 years?
4. Pregnant or nursing?
5. Allergic to ANY medicines. e.g. Penicillin, Aspirin, Local Anaesthetic?
HAVE YOU?
1. A prosthetic heart valve, a history of infective endocarditis, heart transplant or surgery including shunts/conduits or congenital heart disease?
2. Hypertension, angina or pacemaker?
3. Had jaundice, liver, kidney disease or any type of hepatitis?
4. Ever reacted adversely to a General or Local Anaesthetic?
5. Had any serious illness or operation?
6. Ever been refused by the blood transfusion service?
DO YOU?
1.Suffer from chronic bronchitis, asthma or breathing difficulties?
2.Suffer from giddiness, blackouts or epilepsy?
3.Suffer from diabetes?
4.Easily bleed?
5.Carry a warning card?
6.Have any other aspects concerning your health?

Personal Dental Assessment

Confidential Medical History

Contact Us