Your title Your first name(s) Your surname Your home phone Your mobile phone Your email Your address Your postcode

Your occupation Your doctors name Your doctors address Your NHS number

Communication

Please tick your preferred contact method(s) by the practice. This includes appointment reminders and general communication:

Phone via homePhone via mobileSMS messageLetterEmail

Marketing

I DO NOT want to receive any Emails or SMS from us informing you of any offers or promotions including discounts

Your medical health

Are you carrying a medical warrant card?

YesNo

Are you taking any prescribed medicines from your GP?

YesNo

Do you have any allergies including medicines?

YesNo

Do you have any heart condition?

YesNo

Do you have Diabetes?

YesNo

Do you have Epilepsy?

YesNo

Do you have Asthma or Bronchitis?

YesNo

Do you have Liver diseases?

YesNo

Do you have excessive bleeding?

YesNo

Do you have high blood pressure?

YesNo

Do you have any serious illness?

YesNo

Do you have Rheumatic fever?

YesNo

Have you had any surgical operations?

YesNo

Do you have bruising or persistent bleeding?

YesNo

Do you have Osteoporosis?

YesNo

Do you have any infectious diseases including HIV and Hepatitis?

YesNo

Do you have any special needs we should be aware of?

YesNo

Do you have a family history of gum disease?

YesNo

Do you take the oral contraceptive pill?

YesNo

Are you pregnant?

YesNo

Dietary habits

How often do you drink fizzy drinks?

DailyWeeklyRarely

Do you have sugar in tea or coffee?

YesNo

How many units of alcohol do you drink per week?
(1 unit = 1 glass wine, ½ pint beer or lager or 1 measure of spirit)

Do you smoke?

YesNoIn the past

Do you chew any form of tobacco?

YesNoIn the past

Your dental history

Previous dentist Date of last dental examination

How frequently did you attend? Why did you leave your dentist?

How can we help?

We are committed to protecting your personal information. Please see our privacy policy (opens in a new window) to find out how your information is stored and protected.

Medical History Questionnaire

It is important for us to have up to date medical history for all our patients. Please take time to complete the form and answer the following questions. Providing this information helps us treat our patients safely. All information provided will be kept strictly confidential.

Your personal details

Communication

Marketing

Your medical health

Dietary habits

Your dental history

How can we help?

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