The Channings Dental Surgery-Confidential medical history��

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