: Affordable Family Dental Care|Mark Sher|Lennie Bernstein: Medical History

Full Name *

Title *

Date of Birth *

Sex *

Address Line 1 *

Address Line 2

City/Town *

County *

Post Code *

Telephone - home *

Telephone - work

Occupation

How Long Since Last Received Dental Treatment?

Expectant Mother?

No Yes

Your Doctor's Name and Address

1(a) Are you attending or receiving treatment from a doctor, hospital, clinic or specialist? *

No Yes

1(b) If 'yes' please give details:

2(a) Are you taking any medicines from your doctor? (tablets, creams, ointments, injections, other)? *

No Yes

2(b) if 'yes' please give details

3(a) Are you taking or have you taken steriods in the last two years? *

No Yes

3(b) If 'yes' please give details

4(a) Are you allergic to any medicines, foods or materials? *

No Yes

4(b) If 'yes' please give details

5(a) Have you had rheumatic fever or chorez (St. Vitus Dance)? *

No Yes

5(b) If 'yes' please give details

6(a) Have you had jaundice, liver, kidney disease or hepatitis? *

No Yes

6(b) If 'yes' please give details

7(a) Have you ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack? *

No Yes

7(b) If 'yes' please give details

8(a) Have you recently had any blood tests, inoculations etc? *

No Yes

8(b) If 'yes' please give details

9(a) Have you ever had your blood refused by the Blood Transfusion Service? *

No Yes

9(b) If 'yes' please give details

10(a) Have you had a bad reaction to a general or local anaesthetic? *

No Yes

10(b) If 'yes' please give details

11(a) Have you had a joint replacement? *

No Yes

11(b) If 'yes' please give details

12(a) Have you been hospitalised in the last 5 years? *

No Yes

12(b) If 'yes' what for and when?

13(a) Do you have arthritis? *

No Yes

13(b) If 'yes' please give details

14(a) Do you have a pacemaker, or have you had any form of heart surgery? *

No Yes

14(b) If 'yes' please give details

15(a) Do you suffer from hay fever, eczema or any other allergy? *

No Yes

15(b) If 'yes' please give details

16 (a) Do you suffer from bronchitis, asthma or other chest condition? *

No Yes

16(b) If 'yes' please give details

17(a) Do you have fainting attacks, giddiness, blackouts or epilepsy? *

No Yes

17(b) If 'yes' please give details

18(a) Do you have diabetes or does anyone in your family? *

No Yes

18(b) If 'yes' please give details

19(a) Do you bruise easily or following a tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried? *

No Yes

19(b) If 'yes' please give details

20(a) Do you carry a warning card? *

No Yes

20(b) If 'yes' please give details

21(a) Do you ever get cold sores? *

No Yes

21(b) If 'yes' please give details

22 Are there any other aspects concerning your health that you think the dentist should know about?

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