Lead >> MAX

First name

Last name

E-mail

Phone

1. Personal Details

1.1 Your Date of Birth

Please select the year at the top of the calendar before selecting the month and day

1.2 Name of your GP

1.3 What is the name of your GP Surgery

1.4 Emergency Contact Name

1.5 Emergency Contact relationship to you?

1.6 Emergency Contact phone number?

2. General health and lifestyle

2.1 What is the estimate of your general health

Excellent

Good

Fair

Poor

2.2 Have you ever had / been hospitalised for illness or injury

Yes

2.3 Are you a smoker or have you previously smoked?

Yes

2.4 If you answered yes to the above question please state how many per day

2.5 If you answered yes to the above question and have subsequently quit, please state approximately when you quit

2.6 Do you vape?

Yes - (does not contain Nicotine)

Yes - (contains Nicotine)

2.7 Do you regularly drink alcohol?

Yes

2.8 If you answered yes to the above question, approximately what is your weekly alcohol intake (in units)?

3. Allergens

3.1 Have you ever had an allergic reaction to Aspirin, Ibuprofen or Paracetamol

Yes

3.2 Have you ever had an allergic reaction to Penicillin

Yes

3.3 Have you ever had an allergic reaction to Erythromycin

Yes

3.4 Have you ever had an allergic reaction to Tetracycline

Yes

3.5 Have you ever had an allergic reaction to Sulpha

Yes

3.6 Have you ever had an allergic reaction to Local Anaesthetic

Yes

3.7 Have you ever had an allergic reaction to Fluoride

Yes

3.8 Have you ever had an allergic reaction to Metals (Nickel, Gold, Silver etc...)

Yes

3.9 Have you ever had an allergic reaction to Latex

Yes

3.10 Have you ever had an allergic reaction to any other substance that's not listed

Yes

3.11 If applicable, please list the substance/s below

4. Medical

4.1 Have you had any heart issues, or cardiac stent within the last six months

Yes

4.2 Do you have a history of Infective Endocarditis

Yes

4.3 Do you have a artificial heart valve, repaired heart defect (PFO)

Yes

4.4 Do you have a pacemaker or implantable defibrillator

Yes

4.5 Do you have Rheumatic or Scarlet fever

Yes

4.6 Do you have a High or Low blood pressure

Yes

4.7 Have you had a Stroke or are you Taking a blood thinner

Yes

4.8 Do you have any Blood disorder

Yes

4.9 Have you experienced prolonged bleeding with a cut

Yes

4.10 Do you have Emphysema or Sarcoido

Yes

4.11 Do you have Asthma

Yes

4.12 Do you have Breathing or Sleep problems (i.e Snoring)

Yes

4.13 Do you have a Kidney Disease

Yes

4.14 Do you have a Liver Disease

Yes

4.15 Do you have Thyroid, Parathyroic disease or Calcium Deficiency

Yes

4.16 Do you have High Cholesterol or take statins

Yes

4.17 Do you have Diabetes

Yes

4.18 Do you have a Stomach or Duodenal ulcer

Yes

4.19 Do you have any digestive disorders such as gastric reflux

Yes

4.20 Do you have Osteoporosis or Osteopenia

Yes

4.21 Do you have Arthritis

Yes

4.22 Do you have any Head or Neck injuries

Yes

4.23 Do you have epilepsy or convulsions (Seizures)

Yes

4.24 Do you have Cold sores

Yes

4.25 Do you have Hay-fever or Eczema

Yes

4.26 Do you have Hepatitis

Yes

4.27 Do you have HIV or Aids

Yes

4.28 Do you have a Tumour or Abnormal growth

Yes

4.29 Do you receive Radiation Therapy

Yes

4.30 Do you receive Chemotherapy

Yes

4.31 Do you receive Psychiatric treatment

Yes

4.32 Do you take any antidepressant medication

Yes

4.33 Are you currently being treated for any illness

Yes

4.34 Do you get frequent headaches

Yes

4.35 Are you pregnant

Yes

4.36 If applicable, Please state any current or impending medical treatment

4.37 Please list ALL medication you are currently taking

6. Confirmation

6.1 Date of Medical History Form Submission

This confidential form provides us with important information to safeguard your health before commencing any treatment. Please therefore ensure that this is as accurate as possible to the best of your knowledge.By submitting this form, we will securely collect the contents in accordance with our Privacy Policy. To view our privacy policy, please visit: https://hrsdental.co.uk/legalPlease tick the checkbox below to confirm and complete your submission:

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