Medical History Form Home » Medical History Confidential Medical HistoryWe 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.MrsMissDrSir- select your title -Field is required!Field is required!First NameField is required!Field is required!Last NameField is required!Field is required!Your AddressField is required!Field is required!CityField is required!Field is required!PostcodeField is required!Field is required!Date of birthField is required!Field is required!Name / Practice of your GMPField is required!Field is required!Mobile phone number without spaces.Field is required!Field is required!E-mail AddressField is required!Field is required!Home phone number without spaces.Field is required!Field is required!Have you tested positive for COVID-19 in the last 7 days?YesNoField is required!Field is required!Are you waiting for a COVID-19 test or the results?YesNoField is required!Field is required!Do you have a new continuous cough, fever or loss or change in the sense of smell or taste?YesNoField is required!Field is required!Have you been advised by your GP that you are clinically vulnerable or extremely clinically vulnerable (shielding) to COVID-19?YesNoField is required!Field is required!Have you been contacted by NHS Test and Trace in the last 14 days?YesNoField is required!Field is required!Are you currently receiving treatment from any doctor, hospital or clinic?YesNoField is required!Field is required!Are you currently taking any prescribed medicines?YesNoField is required!Field is required!Do you carry a medical warning card?YesNoField is required!Field is required!Do you suffer from allergies to any medicines (eg penicillin) or substances?YesNoField is required!Field is required!If yes, what are you allergic to? …………………Please list[{"f":"allergies","l":"equal","v":"Yes","fa":"","va":""}]Field is required!Field is required!Do you suffer from asthma, bronchitis or other chest condition?YesNoField is required!Field is required!Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?YesNoField is required!Field is required!Do you suffer from heart problems, angina, blood pressure problems or stroke?YesNoField is required!Field is required!Are you diabetic?YesNoField is required!Field is required!Do you suffer from arthritis?YesNoField is required!Field is required!Do you suffer from persistent bleeding following surgery or tooth extraction?YesNoField is required!Field is required!Do you suffer from any infectious diseases (including HIV and hepatitis)?YesNoField is required!Field is required!Have you ever had rheumatic fever?YesNoField is required!Field is required!Have you ever had liver disease (eg jaundice, hepatitis) or kidney disease?YesNoField is required!Field is required!Have you ever had any other serious illness?YesNoField is required!Field is required!Have you ever had blood refused by the blood transfusion service?YesNoField is required!Field is required!Have you ever had a bad reaction to a general or local anaesthetic?YesNoField is required!Field is required!Have you had a joint replacement or other implant in the past six months?YesNoField is required!Field is required!Have you ever had treatment that required you to be in hospital?YesNoField is required!Field is required!Have you ever had heart surgery?YesNoField is required!Field is required!Have you ever or are you currently being treated with bisphosphonate medicine?(Bone disorders)YesNoField is required!Field is required!Do you smoke any tobacco products (or did you in the past)? YesNoField is required!Field is required!If so how many per week?-+[{"f":"tobacco_products","l":"equal","v":"Yes","fa":"","va":""}]Field is required!Field is required!Do you drink alcohol? If yes, how many units per week?- select a option -No AlcoholStandard glass of wine 2 unitsLarge 3Pint 2.3Pint of cider 4.7Spirits single 1 unit- select a option -Field is required!Field is required!Are you pregnant?YesNoField is required!Field is required!Is there any other medical information your dentist might need to know?Add additional detailsField is required!Field is required!Please list any medication you are taking and any further health information below.Add additional detailsField is required!Field is required!Data Privacy & ConsentAt 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:TelephoneLetterTextEmailField is required!Field is required!Inline with our data privacy policy, we will occasionally send out a general newsletter or notification of special offers. Do you consent? YesNoField is required!Field is required!SignaturePlease add your name and date the form.Your First NameField is required!Field is required!Your Last NameField is required!Field is required!Date completedField is required!Field is required!Submit
