Online Medical History Form

Online Medical History Form

Completing medical history information is now a standard and required part of visiting your Dentist.

Accurate dental records can help practitioners to reach a diagnosis by providing detailed information about a patient’s changing oral health. Detailed records can also help to prevent adverse incidents, for example, if the records are not clear the wrong tooth could be treated. Records should also enable another clinician to easily understand a patient’s current state of health and the nature of any care that has been given.

It is essential that we have the latest information to hand when treating our patients, and so you may be required to fill out a new medical history every time you attend.

Your dentist will review your medical history form with you confidentially during your appointment.

In order to help us meet all of your dental health care needs, please complete the following Medical History Form.

Rock House Dental Practice Confidential Medical History

Title:
  • - select your title -
  • Mr.
  • Miss.
  • Mrs.
  • Dr.
  • Prof.
  • Other
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Field is required!
First Name:
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Last Name:
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Gender:
  • - select a option -
  • Male
  • Female
  • Mixed Gender
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Date of Birth:
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Ethnic Group:
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Address:
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City:
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Post Code:
Enter a valid postcode
Enter a valid postcode
Email Address:
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Mobile Phone Number:
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Phone Number:
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Next of Kin & Contact Details
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Doctors Name and Practice Address:
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Medical History Details

The next few pages will ask you questions about your medical history. Click next to move through the pages. Please compete as fully as possible.

Habits

Do you smoke or use nicotine products?
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Field is required!
Field is required!
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Do you chew tobacco, pan, gutka, supari?
Field is required!
Field is required!
Field is required!
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Do you consume alcohol (number of units)?
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Field is required!
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Do you have high sugar frequency / intake?
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Field is required!
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Do you have high acidic food or drink frequency / intake?
Field is required!
Field is required!
Field is required!
Field is required!
Do you take recreational or illegal drugs?
Field is required!
Field is required!
Field is required!
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Heart

Have you ever suffered with Rheumatic Fever?
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Field is required!
Field is required!
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Do you have high blood pressure or hypertension?
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Have you ever undergone heart surgery?
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Do you wear a pacemaker?
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Do you have a heart murmur?
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Do you have angina?
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Have you ever suffered with thrombosis?
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Have you ever suffered a heart attack?
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Field is required!
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Do you have any other heart conditions?
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Field is required!
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Blood

Do you have Hepatitis A, B or C?
Field is required!
Field is required!
Field is required!
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Do you have HIV or AIDS?
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Field is required!
Field is required!
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Have you ever had an abnormal blood test result?
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Field is required!
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Ever had blood refused by a blood transfusion service?
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Do you have anaemia?
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Do you have sickle cell disease?
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Do you have haemophilia?
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Do you have blood clotting problems?
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Do you have any other blood conditions?
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Allergies

Do you have an allergy to penicillin?
Field is required!
Field is required!
Field is required!
Field is required!
Do you suffer with hay fever?
Field is required!
Field is required!
Field is required!
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Do you have an allergy to latex?
Field is required!
Field is required!
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Do you have an allergy to any medicines?
Field is required!
Field is required!
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Do you have an allergy to anti-tetanus serum?
Field is required!
Field is required!
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Do you have an allergy to plants?
Field is required!
Field is required!
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Do you have Eczema?
Field is required!
Field is required!
Field is required!
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Are you allergic to any foods?
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Are you allergic to aspirin?
Field is required!
Field is required!
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Have you ever had a bad reaction to general anaesthetic?
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Have you ever had a bad reaction to local anaesthetic?
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Do you have any other allergy?
Field is required!
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Chest & Lungs

Do you have any form of COPD?
Field is required!
Field is required!
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Do you have cystic fibrosis?
Field is required!
Field is required!
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Have you ever had pleurisy or pneumonia?
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Do you suffer from asthma?
Field is required!
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Have you ever had any surgery to your chest?
Field is required!
Field is required!
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Do you have any other chest condition?
Field is required!
Field is required!
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Other Conditions

Have you ever had any liver disease (e.g. jaundice)?
Field is required!
Field is required!
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Have you ever had any kidney disease?
Field is required!
Field is required!
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Do you (or a blood relative) suffer with diabetes?
Field is required!
Field is required!
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Do you suffer with acid reflux?
Field is required!
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Have you ever had an eating disorder?
Field is required!
Field is required!
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Do you have a hiatus hernia?
Field is required!
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Do you suffer from epilepsy?
Field is required!
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Do you have bone or joint disease?
Field is required!
Field is required!
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Do you have an artificial joint?
Field is required!
Field is required!
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Do you suffer with fainting attacks, giddiness or blackouts?
Field is required!
Field is required!
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Have you ever suffered with cancer?
Field is required!
Field is required!
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Any other (past or current) serious or infectious disease?
Field is required!
Field is required!
Field is required!
Field is required!

Warnings

Are you pregnant or possibly pregnant?
Field is required!
Field is required!
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Are you currently breastfeeding?
Field is required!
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Do you require antibiotic cover?
Field is required!
Field is required!
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Have you taken steroids in the last 2 years?
Field is required!
Field is required!
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Do you take bisphosphonates?
Field is required!
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Do you have problems being reclined?
Field is required!
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Are you currently under the treatment of a doctor?
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Do you carry a warning card?
Field is required!
Field is required!
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Do you bleed or bruise excessively following surgery?
Field is required!
Field is required!
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Do you suffer with a phobia or fear of the dentist?
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Other treatment that has needed you to be hospitalised?
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Anything else your dentist should know?
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Medications Taken

Are you currently taking any medications?
Field is required!
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Provide a detailed list of any medications that you take
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Field is required!

Oral Health Survey

The next few pages will ask you questions about your dental health. Please complete as fully as you can. Click next to move through the pages
Areas of concern (Tick all those statements that apply to you)
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Field is required!
Appearance (Tick all those statements that apply to you)
Field is required!
Field is required!
Information (Tick all those statements that apply to you)
Field is required!
Field is required!
Dental Practice Membership (Tick all those statements that apply to you)
Field is required!
Field is required!
How happy are you with the state of your general dental health? (1 being very unhappy, and 5 being very happy)
Field is required!
Field is required!
How anxious or nervous are you regarding dental treatment? (1 being very anxious, and 5 being not at all anxious)
Field is required!
Field is required!
How happy are you with the appearance of your smile? (1 being very unhappy, and 5 being very happy)
Field is required!
Field is required!
How happy are you with the colour of your teeth? (1 being very unhappy, and 5 being very happy)
Field is required!
Field is required!
How happy are you with the alignment (straightness) of your teeth? (1 being very unhappy, and 5 being very happy)
Field is required!
Field is required!
How likely are you to have cosmetic skin injections to improve fine lines and wrinkles in your skin? (1 being very unlikely, and 5 being very likely)
Field is required!
Field is required!
How likely are you to have dental sedation whist you are having dental treatment? (1 being very unlikely, and 5 being very likely)
Field is required!
Field is required!
Submit