AdminPatients Medical History Form - Draft example

Are you Currently receiving treatment from doctor, hospital or clinic?
Are you currently taking any prescribed medicines (e.g. tablets, ointments or inhalers, including contraceptives and hormone replacement therapy)?
Are you carrying medical warning card?
Do you suffer from allergies to any medicines (e.g. penicilin), substances (e.g. latex/rubber) or foods?
Do you suffer from hay fever or eczema?
Do you suffer from bronchitis, asthma, or other chest conditions?
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
Do you suffer from heart problems, angina, blood pressure?
Are you diabetic (or anyone in your family)?
Do you suffer from arthritis?
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
Do you suffer from any infections diseases (including HIV and hepatitus)?
Have you ever had rheumatic fever or chorea?
Have you ever had liver disease (e.g. jaundice, hepatitus) or kidney disease?
Have you ever had any other serious illness?
Have you ever had blood refused by the Blood Transfusion Service?
Have you ever had a bad reaction to general or local anaesthetic?
Have you ever had a joint replacement or other implant?
Have you ever had treatment that required you to be in hospital?
Have you ever had a heart surgery?
Have you ever had brain surgery?
Did you receive growth hormone treatment before the mid 1980's?
Do you have any close relatives (parent, sibling, child, grandparent, or grandchild) with creutzfeldt jakob disease?
Do you have regularly drink more than 14 units of alcohal per week?
Do you smoke any tobacco products now (or did you in past)?
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)?