The Endodontic Practice

Medical History

ENDODONTIC PRACTICE CONFIDENTIAL MEDICAL HISTORY

Please complete the form below and submit it electronicaly, or if you prefer, you can print out the form from this link and fill it out and bring it with you to your appointment.

    Your Details
    Title
    Name
    Date of Birth
    Patient telephone number
    Patient email address
    Patient Address
    Post code
    Your Doctors Details
    Doctors Name
    Practice Name
    Telephone number
    Address
    Postcode
    The contents of this questionnaire are confidential and will provide us with essential information to allow us to meet your needs and to safeguard your health.

    ARE YOU
    1) Attending or receiving treatment from a doctor, hospital, clinic or specialist?
    2) Taking or using any medicine, pills, tablets or any other drug?
    3) Allergic to any medicines (e.g penicillin), foods or materials?
    4) Pregnant or planning to become pregnant?
    If you answered Yes to any of the above, please elaborate here

    HAVE YOU
    1) Had rheumatic fever or chorea (St. Vitus’ Dance)?
    2) Had hepatitis, jaundice, liver disease or kidney disease?
    3) Ever been told you have a heart murmur or heart problem?
    4) Suffered from angina, high blood pressure or a heart attack?
    5) Ever had your blood refused by the Blood Transfusion Service?
    6) Had a joint replacement?
    7) Taken steroids in the last two years?
    8) Been hospitalised?
    9) Been diagnosed, or had reason to believe, that you might be HIV Positive?
    10) Had Growth/Pituitary Hormone Treatment since 1984?
    11) Had brain surgery including dura mater grafts?
    12) A close relative with Creutzfeldt Jakob Disease?


    DO YOU
    1) Bruise easily or, following a tooth extraction, surgery or injury have you or anyone in your family, bled so as to cause worry or seek medical attention?
    2) Have a pacemaker, or have you had any form of heart surgery?
    3) Suffer from bronchitis, asthma or chest conditions?
    4) Have fainting attacks, giddiness, blackouts or epilepsy?
    5) Have diabetes or does anyone in your family?
    6) Have arthritis?
    7) Carry a steroid warning card?
    8) Smoke cigarettes/cigars/pipe or chew tobacco?
    Quantity per day
    9) Drink alcohol?
    Number of units per week (1 Glass of wine is 1.5 units)
    10) Have any objections to us holding computerised information about your treatment?
    Are there any other aspects of your health that you feel your dentist should know?

    Details of any Yes replies will be discussed with the Dentist.

    I consent to the treatment set out in the information sent to me through the post or email.

    Your will be asked to sign a copy of this form, when you visit the surgery.