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Medical History Form

01. Personal Details

02. Emergency Contact Details

03. Medical History (required)

Do you have, or have you had any of the following?

Anaemia

Arthritis

Artificial Joints/ Heart Valves

Bleeding Problems

Bone Problems (e.g. Osteoporosis)

Cancer

Chest Problems (e.g. Asthma/ COPD)

Chemotherapy/ Radiotherapy

Coldsores

Diabetes

Epilepsy/Seizures/Fits

Heart Problems (e.g. Heart Attack)

High/ Low Blood Pressure

HIV/ AIDS

Kidney Problems

Liver Problems (e.g. Hepatitis)

Mental Health Issues

Organ Transplant

Rheumatic Fever/Infective Endocarditis

Stomach Problems (e.g. Reflux, IBS)

Stroke/ Mini Stroke

Surgery/ Operations

If you have ticked any of the above or if you feel anything else is medically relevant, then please provide
further details in the space below

If you take any medication, please list them all in the space below:

If you have any allergies, please list them all in the space below:

04. Lifestyle History

Do you smoke? (required)

If yes, what do you smoke?

Do you drink alcohol (required)

Have you ever been dependant on drugs? (required)

05. Females only

Are you pregnant? (required)

If yes, when is your baby due?

Are you breastfeeding?

06. Signature

Please check below to certify that you have understood the above information and that your answers are accurate and up-to-date. Any incorrect information can be dangerous to your health, so please inform your dentist of any changes

I am the: (required)