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55 St Thomas’s Road, Chorley, Lancashire, PR7 1JE

Confidential Medical History Form

We ask you for information about your general health to help us treat you safely. Please fill the form below with your contact details, answer the health questions and then sign the form. We will use this form during later visits to discuss any changes in general health. All information will be kept strictly confidential by the people caring for you.

Sex
In the event of an emergency, please contact:
Doctor's Details:
Are you currently:
Receiving treatment from a doctor, hospital or clinic?
Taking any prescribed medicines (cg tablets, ointments, injections or inhalers, including contraceptives and hormone replacement therapy)?
Carrying a medical warning card?
Pregnant or possibly pregnant?
Have you ever suffered from:
Allergies to medicines (eg penicillin), substances (eg latex/rubber) or foods?
Bronchitis, asthma or other chest condition?
Fainting attacks, giddiness, blackouts, epilepsy?
Heart Problems, angina, blood pressure problems, or stroke?
Diabetes (or does any one in your family)?
Bone or joint disease?
Bruising or persistent bleeding following injury, tooth extraction or surgery?
Liver disease (eg jaundice, hepatitis) or kidney disease?
Any other serious illness or infectious disease?
Blood refused by the Blood Transfusion Service?
A bad reaction to general or local anaesthetic?
Treatment that requıres you to be in hospital?
Heart surgery?
Alcohol
How many units of alcohol do you drink per week? (A unit is half a pint of lager, a single measure of spirits or a single glass of wine/aperitif).
units of alcohol
Smoking
Do you smoke any tobacco products now (or did you in the past)
times per day
Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)
times per day
Please give any details which your dentist might need to know about, such as self-prescribed medicine (eg aspirin) or any disabilities you may have.
THIS FORM WAS COMPLETED BY (PLEASE CHECK 1 BOX):
Patient Signature:
Date:
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