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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)