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Simply fill out the form below and click submit and we’ll be in touch shortly. Alternatively you can pop into the surgery.

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Medical History Form
First Name
Last Name
How long since you last visited a dentist?
Date of Birth
Date of Birth
Your Details
Your Home Addressmore details
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Home Telephone Number
Work Telephone Number
Mobile Telephone Numberyour full name
Occupationyour full name
Your Doctor's Details
Your GP's Nameyour full name
Surgey Addressmore details
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Your Medical History
Are you attending or receiving treatment from any doctor?
Are you taking any medicines or tablets from your doctor?
Are you taking or have you taken steroids in the last two years?
Are you allergic to any medicines, food or materials?
Have you ever had jaundice, liver or kidney disease or hepatitis?
Have you ever been told that you have a heart problem or had a heart attack?
Have you ever had infective endocarditis or a heart valve replaced or any form of heart surgery?
Have you been diagnosed with either high or low blood pressure?
Have you had any blood tests recently?
Have you ever had a reaction to a local or general anaesthetic?
Have you ever had a stroke?
Have you ever had a major operation or recently received hospital treatment?
Have you ever had your blood refused by the Blood Transfusion Service?
Have you ever been diagnosed or suspected as having VCJD or being HIV positive?
Do you have a pacemaker?
Do you suffer from bronchitis or asthma?
Do you bruise easily or have you ever bled excessively?
Do you have fainting attacks, giddiness or epilepsy?
Do you have diabetes?
Do you carry a warning card?
Do you smoke?
How many a day do you smoke?
Do you drink alcohol?
How many units a week do you drink?
CommentsAre there any other aspects of your health that you feel we should know about?
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