Beechcroft Dental Practice Beechcroft, New Costessey, nr5 0rs 01603 747651



Download 64.09 Kb.
Date conversion29.11.2016
Size64.09 Kb.


Beechcroft Dental Practice

Beechcroft, New Costessey, NR5 0RS

01603 747651




Confidential Medical History

Your dentist needs to know of any problems which may affect your treatment. Please answer the questions as accurately as possible. To be completed by Patient, Parent or Guardian.


SURNAME_____________________________________________FIRST NAME________________________________________

TITLE SEX DATE OF BIRTH__________________________________________ ADDRESS__________________________________________________________________________________________________ __________________________________________________________________POSTCODE ______________________________ TELEPHONE Home _____________________________Mobile_____________________Work __________________________


Are you in receipt of any exemption? If yes which one?

What is your National Insurance Number?



Name, address and telephone number of doctors




Are you?

Please circle

Give details

Expectant Mother

y

n

Date baby due ______________

Receiving treatment from a doctor, hospital or clinic?

y

n




Taking any medication? List medication please overleaf

Carrying a warning card?



y

y


n

n




Allergic to any medicines? Including Chlorhexidine

y

n




Have you had/being treated for?

Hepatitis? Recent jaundice?

y

n




Infective Endocarditis, Heart Valve Replacement or Shunt/Conduit

y

n




High Blood Pressure

y

n




Heart complaint eg Angina, Stroke, Attack, murmur?

y

n




Are you/have you been treated for Osteoporosis?

y

n




Bleed excessively from cuts or if you have a tooth extracted?

y

n




Bronchitis, Asthma, or any other chest condition?

y

n




Diabetes?

y

n




Suffer from Epilepsy, Fainting Attacks or Blackouts?

y

n




Any other serious illness or operations?

y

n




Frequent headaches and associated jaw pain?

y

n




Is there any chance that you have become infected with HIV?

y

n




Dental Questions

Do you clench/grind your teeth?

y

n




Are you happy with your teeth and gums?

y

n




Do your gums bleed on brushing?

y

n




Difficulty chewing/eating food?

y

n




Teeth loose/developing gaps?

y

n




Unhappy with the aesthetics of your teeth?

y

n




What concerns you most about visiting the dentist?

When was your last dental visit?



Do you drink alcohol? No of Units/week

Do you smoke? Have you smoked in the past? Quantity? PTO


Further Details. If there are any other aspects of your health that you feel may be relevant to your treatment and of which the dentist should be aware, please give details below if required.
Signature Date


How did you hear about our practice?




Please indicate if you would be happy to receive communications from us via text message: Yes No




Medication/information:





Date

Signature

Date

Signature


























































































































































































































































































































The database is protected by copyright ©dentisty.org 2016
send message

    Main page