Medical History Form – South Lane Dental

- Patient Details
- Patient Name*
  Title First Name Surname
- Patient Address*
  Address Line 1 Address Line 2 City Postcode
- Patient Date of Birth*
  
  Day
  Month
  Year
- Email Address
- Home Phone Number
- Mobile Phone Number
- Your Occupation
- Ethnicity
- Your GP's Details
- Doctor's Name*
- GP Surgery Name*
- Practice Address
  Address Line 1 Address Line 2 City Postcode
- COVID 19 Specific Medical History
- Have you been diagnosed with coronavirus?*
  - Yes
  - No
- Have you been in contact with someone with confirmed/suspected coronavirus?*
  - Yes
  - No
- Are you or your household self-isolating?*
  - Yes
  - No
- Have had any symptoms of the coronavirus in the last 14 days?*
  - Yes
  - No
- Are you considered a ‘shielded/ vulnerable’ patient due to underlying health conditions?*
  - Yes
  - No
- Do you have any mobility issues?*
  - Yes
  - No
- As you've answered yes to a screening question, please give further details about your answer
- You are a category 1 patient
- You are a category 2 patient
- You are a category 3 patient
- Carer/guardian risk assessment:
- Will you need a chaperone at your appointment?*
  - Yes
  - No
- If yes, in what capacity? Please give the name and phone number of the chaperone.*
- It may be best if they were to wait for you outside to reduce the transmission risk of COVID-19. Would this be acceptable to you?*
  - Yes
  - No
- Your Medical History Details
  Do you have any of the following.
- Are you currently taking any prescribed or non prescribed medication?*
  - Yes
  - No
- Medication List*
  Medication Dose When Taken (How Often) For Which Condition
- Rheumatic Fever
  - Yes
  - No
- High Blood Pressure
  - Yes
  - No
- Stroke
  - Yes
  - No
- Epilepsy
  - Yes
  - No
- Fainting Attacks
  - Yes
  - No
- Blackouts
  - Yes
  - No
- Asthma
  - Yes
  - No
- Hayfever
  - Yes
  - No
- Eczema
  - Yes
  - No
- Steroid Treatments
  - Yes
  - No
- Heart Complaint
  - Yes
  - No
- Please enter details
- Are you Diabetic?
  - Yes
  - No
- Please enter details
- Excessive bleeding (blood thinning meds)
  - Yes
  - No
- Please enter details
- Arthritis/Osteoporosis
  - Yes
  - No
- Please enter details
- Operation in last 2 years
  - Yes
  - No
- Please enter details
- Joint replacement
  - Yes
  - No
- Please enter details
- Blood-borne viruses (HIV, Hepatitis B/C)
  - Yes
  - No
- Please enter details
- Any other medical condition
  - Yes
  - No
- Please enter details
- Do you or are you:
- Currently Pregnant?
  - Yes
  - No
- If yes, please enter details (eg due date)
- Carry a warning card
  - Yes
  - No
- If yes, please enter details
- Allergic to anything (food/penicillin/latex etc)
  - Yes
  - No
- If yes, please enter details
- A smoker (including tobacco/vape)
  - Yes
  - No
- If yes, please enter details (amount per day)
- Drink alcohol
  - Yes
  - No
- If yes, please enter details (units per week)
- Any Other Information
- If there is any other information which has not been asked on this form that you feel the dentist should know about?
- Consent and Signature
- I confirm that the above information is correct to the best of my knowledge.*
  - I CONFIRM
- I am aware that by attending the practice there is the possibility that I may be putting myself and family members at risk from coronavirus*
  - I CONFIRM
- I give my consent for the above information to be stored in the interests of maintaining my oral health and for the practice to contact me about my treatment*
  - I CONFIRM
- My preferred method of contact
  - Email
  - Phone
  - Text
- Signature
Phone
This field is for validation purposes and should be left unchanged.

Medication	Dose	When Taken (How Often)	For Which Condition

South Lane Dental Medical History Pre-Appointment Form

Patient Details

Your GP's Details

COVID 19 Specific Medical History

You are a category 1 patient

You are a category 2 patient

You are a category 3 patient

Carer/guardian risk assessment:

Your Medical History Details

Do you or are you:

Any Other Information

Consent and Signature

You are now in a secure area