GENERAL INFORMATION MEDICAL HISTORY

Please note that it is important to fill in all the fields before submitting. Thank you.

Title :	Mr Mrs Ms Miss Dr
Patient Name :
	*First Name :	Middle Name :	*Surname :

*Your birthday :
Marital Status :	Single Married Partnered Divorced/Separated Widowed

*Current Address :			Town :
	City :		Postcode :

*Home Phone :	()--	Work Phone:	()---
Cell Phone :	()--	*E-mail :

Occupation :
Partner's name :

How did you hear about us?
Whom may we Thank for referring you?

General Dentist's Details -
Dentist's Name :		Telephone :	()--

Dentist's Address :			Town :
	City :		Postcode :

General Doctor's Details -
Doctor's Name :		Telephone :	()--

Doctor’s Address :			Town :
	City :		Postcode :

In An Emergency Is There Anyone We Can Contact?
His/Her Name :
Relationship to Patient :		Telephone :	()--

Have You Had Or Do You Suffer From Any Of The Following?
Rheumatic fever or chorea (St Vitas’s Dance)	Yes No
Heart problems or high blood pressure	Yes No
Severe bleeding or a family history of bleeding	Yes No
Blood trouble, Anaemia, Leukaemia	Yes No
Chest trouble including infection, e.g. TB, Bronchitis	Yes No
HIV, Yellow Jaundice, Hepatitis, Liver/Kidney disease	Yes No
Asthma, Hay Fever, Eczema or other allergy	Yes No
Fits, Faints or Epilepsy	Yes No
Diabetes	Yes No

Have you visited your doctor in the last two years?	Yes No
If for more than coughs / colds, what for?
Are you allergic to Penicillin or any other drugs?	Yes No
If allergic to another drug, which?
Are you using any medication (inc. ointments/injections)?	Yes No
If yes, what and how often?
Have you had any serious illness or operation?	Yes No
If yes, please specify

How much do you Smoke per day?
How much do you Drink per day?
Please state your ethnic group
Is there anything else you might feel is of medical importance?


*Signature	Date

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"I must express my complete satisfaction with the work that was carried out by the team at the Dental Clinic - I had removal of teeth, and implants and all associated work connected with the making of new dentures and for improving my confidence. I would also like commenmd the professionalism to all ataff and in particular Peter Silverside for his enduring patience and tolorance in resolving a rather complex situation. I would thoroughly recommend the practice to all with dental problems. PB - Sidcup

GENERAL INFORMATION MEDICAL HISTORY

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