Title

Name

Date of Birth

Sex Male/Female

Address

Occupation

How Long since you last visited the dentist?

Tel No Home

             Work

Dr.’s Name and address

No

Yes

If Yes Please give any Details

Are you:

1. Attending or receiving treatment from a doctor, hospital , clinic or specialist?

2. Taking any medicines?

3. Taking or have you taken Steroids in the last two years?

4. Allergic to any medicines?

Have you:

Had Rheumatic fever?

Had Jaundice, Liver or Kidney disease or Hepatitis?

Ever been told you have a Heart murmur or Heart problem, Angina, Blood Pressure or a heart attack?

Had any recent Blood tests 

Ever had your blood refused by the blood transfusion service?

Had a reaction to a local or general anaesthetic?

Had a Joint replacement?

Been hospitalised? If yes for what?

Do You:

Have Arthritis?

Have a Pacemaker orHave you had any form of Heart Surgery?

Suffer from hay fever, eczema or any other allergy.

Suffer from Bronchitis, asthma or any chest condition.

Fainting attacks, blackouts , giddiness or epilepsy.

Have Diabetes?

Bruise easily or bleed excessively?

Do you smoke Y/N - how many per day

Carry a warning card?

Do You or have any members of you family had CJD(Creutzfeldt-Jakob Disease)

Any other aspects of your health you think we should know about?

Completed by

Date . ……………………………………….Signature

***Use for next  6  Monthly Examinations -Please amend the above list and sign below***

Any changes in your health or medication since your last course of treatment?

Date ………………………………………...Signature

Date…………………………………………Signature