Medical History Form

On this page patients can complete a digital Medical History form and submit it to us.

Alternatively, there is the option to download the form (as a .PDF), print it off and complete it that way. You can then scan the form and send it to us via our ‘Uploads’ page, post it to us, or bring the form in yourself.

DOWNLOAD THE MEDICAL HISTORY FORM (.PDF)

Medical History Form

  • Patient details:
  • (applicable to NHS patients only)
  • MM slash DD slash YYYY
  • 1. Are you currently: (Please answer all of the questions below by ticking ‘yes’ or ‘no’. If you answer ‘yes’, please provide additional details)
    • (used for hormone replacement therapy, menopause and osteoporosis)
    • (if yes, please list)
  • 2. Have you ever had: (Please answer all of the questions below by ticking ‘yes’ or ‘no’. If you answer ‘yes’, please provide additional details)
    • (e.g latex, runner)
    • (e.g latex, runner)
    • (if yes, what for and when?)
  • 3. Do you?: (Please answer all of the questions below by ticking ‘yes’ or ‘no’. If you answer ‘yes’, please provide additional details)
  • 4. Alcohol and tobacco usage: (A unit of alcohol is half a pint of lager, a single measure of spirits, or a single glass of wine/aperitif)
    • (if so, please give an indication number of units consumed per week)
    • (if so, please give an indication of quantity per day)
    • (if so, please give an indication of quantity per day)
    • (if so, please give an indication of quantity per day)
  • 5. Further medical information:
    Please give any other details which your dentist might need to know (e.g self-prescribed medicines such as Aspirin)
  • 6. Signature:
    (if not completed by patient, please also state relationship to patient)
  • MM slash DD slash YYYY

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