Medical Questionnaire

Name*

Title First Last

Date of Birth*

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General Medical Practioner Details

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Medical History

Are you currently undergoing any medical treatment?*

Yes
No

Have you been admitted to hospital or had surgery within the last 2 years?*

Yes
No

Are you currently taking any medications?*

Yes
No

Do you have any known allergies?*

Yes
No

Do you carry a medical warning card?*

Yes
No

Are you pregnant?*

Yes
No

Please list any allergies including to medications, foods or materials (eg. LATEX):

Medications

Medication	Strength	Dose
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Please list any medications you are currently taking.

Check all current and past conditions:

Please Supply Details of Any Checked Boxes Below

Family History

Check all that apply to you or your immediate family:

Asthma / Lung Problems
Cancer
Cardiac Disease
Diabetes
Hypertension (high blood pressure)
Periodontal (gum) Disease
Psychiatric Disorders
Seizure Disorder
Stroke

Please Supply Details of Any Checked Boxes Below

Dental Specific Medical

Have you ever had a bad reaction to dental treatment, including local anaesthetic?*

Yes
No

Do you bruise easily, suffer from prolonged bleeding, or take anti-clotting or anti-platelet medication?*

Yes
No

Do you suffer from fainting, black outs, giddiness or epillepsy?*

Yes
No

Have you ever had or have upcoming joint replacement surgery?*

Yes
No

Do you have Osteo or Rheumatoid Arthritis?*

Yes
No

Do you suffer from cold sores?*

Yes
No

Have you ever tested positive for:*

N/A
HIV
Hepatitis B
Hepatitis C
Rheumatic Fever

Do you take medication for Osteoporosis or bone density?*

No
Orally
Intravenously (IV)

Do you routinely carry on your person:*

N/A
An inhaler
An epipen or similar
GTN spray

Social History

What is your average weekly consumption of alcohol in units?

Eg. Pint of lager is 3 units and standard glass of wine

If you smoke what is your average per day?

Please include e-cigarettes and vaping

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01895 832238