Patient Medical History

Surname

Forename

Date of Birth

Email

Mobile telephone number

Address&postcode

Doctor/GP Name

Doctor/GP Surgery Address

Do you currently have any Covid-19 symptoms? YesNo

How did you hear about the practice? Family/friendSocial MediaGooglePassing By

Please tick these boxes if you DO NOT wish to receive EmailText

Number

Receiving treatment from a doctor/hospital/clinic? YesNo

Taking any medicines? Carrying a warning card or bracelet? (Pills/medicines/inhalers/injections/contraception/patches) YesNo

Are you/could you be pregnant? YesNo

Have any allergies? (including LATEX, medicines, foods,pollen etc) YesNo

Have any chest conditions? (including asthma) YesNo

Any heart problems (including murmurs, high or low blood pressure, angina) YesNo

Do you have epilepsy? (Or other fits or faints) YesNo

Do you have diabetes or a family history of diabetes? YesNo

Bleed or bruise abnormally after injury / surgery, including dentistry? YesNo

Had any infectious conditions (including hepatitis, HIV or Herpes) or had blood donation refused? YesNo

Had rheumatic fever? YesNo

Liver disease (including jaundice or cirrhosis)? YesNo

Had any serious illness hospital treatment or surgery in the last 2 years? YesNo

Do you drink alcohol? (1 unit =1/2 pint beer/lager. 1 glass of wine or 1 measure of spirit) YesNo

Do you smoke tobacco / chew tobacco? (Pan/gutkha/supari) YesNo

Do you weigh less than 22 stone? YesNo

Please state your favourite kind of music (So we know the kind of music to have on in surgery to make your experience here more enjoyable).

1) What do you like about your smile and would you change anything?

2)Do you suffer with bleeding gums or bad breath?

3) Do you have any missing teeth you would like to replace?