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Patients Medical History Form - Draft example
Yes
No
Are you Currently receiving treatment from doctor, hospital or clinic?
Yes
No
Are you currently taking any prescribed medicines (e.g. tablets, ointments or inhalers, including contraceptives and hormone replacement therapy)?
Yes
No
Are you carrying medical warning card?
Yes
No
Do you suffer from allergies to any medicines (e.g. penicilin), substances (e.g. latex/rubber) or foods?
Yes
No
Do you suffer from hay fever or eczema?
Yes
No
Do you suffer from bronchitis, asthma, or other chest conditions?
Yes
No
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
Yes
No
Do you suffer from heart problems, angina, blood pressure?
Yes
No
Are you diabetic (or anyone in your family)?
Yes
No
Do you suffer from arthritis?
Yes
No
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
Yes
No
Do you suffer from any infections diseases (including HIV and hepatitus)?
Yes
No
Have you ever had rheumatic fever or chorea?
Yes
No
Have you ever had liver disease (e.g. jaundice, hepatitus) or kidney disease?
Yes
No
Have you ever had any other serious illness?
Yes
No
Have you ever had blood refused by the Blood Transfusion Service?
Yes
No
Have you ever had a bad reaction to general or local anaesthetic?
Yes
No
Have you ever had a joint replacement or other implant?
Yes
No
Have you ever had treatment that required you to be in hospital?
Yes
No
Have you ever had a heart surgery?
Yes
No
Have you ever had brain surgery?
Yes
No
Did you receive growth hormone treatment before the mid 1980's?
Yes
No
Do you have any close relatives (parent, sibling, child, grandparent, or grandchild) with creutzfeldt jakob disease?
Yes
No
Do you have regularly drink more than 14 units of alcohal per week?
Yes
No
Do you smoke any tobacco products now (or did you in past)?
Yes
No
Do you chew tobacco, pan, use gutka or supari now (or did you in past)?
Please provide any information which your dentist might need to know about, such as self prescribed medicines (e.g. aspirin)?