Medical History Form

Confidential Medical History


We ask you questions about your general health to help us treat you safely. Please complete this form as fully as possible. All details will be kept confidential by the people caring for you and not shared by third parties without your consent. Please use the area overleaf to provide additional information.
  • - select your title -
  • Mr.
  • Mrs
  • Miss
  • Dr
  • Sir
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Have you tested positive for COVID-19 in the last 7 days?
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Are you waiting for a COVID-19 test or the results?
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Do you have a new continuous cough, fever or loss or change in the sense of smell or taste?
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Have you been advised by your GP that you are clinically vulnerable or extremely clinically vulnerable (shielding) to COVID-19?
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Have you been contacted by NHS Test and Trace in the last 14 days?
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Are you currently receiving treatment from any doctor, hospital or clinic?
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Are you currently taking any prescribed medicines?
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Do you carry a medical warning card?
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Do you suffer from allergies to any medicines (eg penicillin) or substances?
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If yes, what are you allergic to? …………………
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Do you suffer from asthma, bronchitis or other chest condition?
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Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
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Do you suffer from heart problems, angina, blood pressure problems or stroke?
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Are you diabetic?
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Do you suffer from arthritis?
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Do you suffer from persistent bleeding following surgery or tooth extraction?
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Do you suffer from any infectious diseases (including HIV and hepatitis)?
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Have you ever had rheumatic fever?
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Have you ever had liver disease (eg jaundice, hepatitis) or kidney disease?
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Have you ever had any other serious illness?
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Have you ever had blood refused by the blood transfusion service?
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Have you ever had a bad reaction to a general or local anaesthetic?
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Have you had a joint replacement or other implant in the past six months?
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Have you ever had treatment that required you to be in hospital?
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Have you ever had heart surgery?
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Have you ever or are you currently being treated with bisphosphonate medicine?(Bone disorders)
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Do you smoke any tobacco products (or did you in the past)?
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If so how many per week?
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Do you drink alcohol? If yes, how many units per week?
  • - select a option -
  • No Alcohol
  • Standard glass of wine 2 units
  • Large 3
  • Pint 2.3
  • Pint of cider 4.7
  • Spirits single 1 unit
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Are you pregnant?
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Is there any other medical information your dentist might need to know?
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Please list any medication you are taking and any further health information below.
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Data Privacy & Consent


At Evesham Place Dental Practice, we take great care with all the Personal Data we hold to ensure we comply with best professional practice and within the law. For a full copy of our Data Privacy Notice please ask at reception or look on our website.

In order to comply with the General Data Protection Regulations (GDPR), we need you to confirm below that you are happy for us to use the details we hold.

If you give us your mobile number we will use it to provide text reminders for your appointments. If you provide your email address then we may use this to send you any documents such as treatment plans or customer surveys. We can also send newsletter (produced by Reid Media) periodically to keep you up to date with developments in the practice.

This information will not be shared with any other third parties without your consent.
Please tick if you are happy for us to contact you by:
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Inline with our data privacy policy, we will occasionally send out a general newsletter or notification of special offers. Do you consent?
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Signature


Please add your name and date the form.
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