medical-history-form - Enamour Dente

Online Medical History Form

Are you a new or existing patient?

New Patient Existing Patient

Title

Mr Mrs Ms Miss Other

Gender

Male Female

Name

Date Of Birth

Street Address

Post Code

Contact Number

Work Number

Occupation

Permission to contact

By completing this section you acknowledge that you next of kin may be contacted in case of a medical emergency

Emergency Contact Name

Emergency Contact Contact Number

Relationship To You

GP Clinic Name and Address

GP Name

GP Telephone Number

Have you been tested for COVID-19?

Yes No

Have you had a COVID-19 antibody test?

Yes No

Have you or anyone you live with travelled outside the UK in the last two weeks?

Yes No

Do you currently have ANY of these symptoms: a new continuous cough, a high temperature,a loss of, or change in, your normal sense of taste or smell (anosmia)?

Yes No

Has anyone in your household (including yourself) been diagnosed (tested positive) with Covid-19 in the last 14 days?

Yes No

COVID-19 Details

When did you last visit the dentist?

1-3 months 3-6 months 6-12 months 1-2 years >2 years

Do you have any dental pain/problem at present?

Yes No

Are you anxious/uncomfortable/have a phobia visiting the dentist?

Yes No

Please add any relevant dental history here

Which treatment/s are you interested in?

Check-up Hygiene Veneers/Lumineers Dental Implants Smile Makeover Root Canal Teeth Whitening Fillers/Botox Orthodontics Invisalign Other

Are you currently pregnant or possibly pregnant?

Yes No

Are you currently experiencing any dental pain/problem?

Yes No

Are you carrying a medical warning card?

Yes No

Taking any prescribed medications?

Yes No

Please add any relevant information and list any medications that you are taking

Do you have any allergies to medicines (e.g. penicillin)?

Yes No

Are you allergic or intolerant to any foods (e.g. nuts)?

Yes No

Are you allergic to any substances (e.g. latex/rubber)?

Yes No

Do you suffer from hay fever or exzema?

Yes No

Do you suffer from bronchitis, asthma or other chest conditions?

Yes No

Do you suffer from epilepsy/fits?

Yes No

Do you suffer from fainting attacks, giddiness, blackouts?

Yes No

Do you suffer from muscle problems (e.g. myopathy, dystrophy, paralysis)?

Yes No

Do you suffer from heart problems (e.g. angina, blood pressure problems or stroke)?

Yes No

Do you suffer from Diabetes (Type I/II or family history of diabetes)?

Yes No

Do you suffer from Neurological diseases(e.g. Multiple Sclerosis)?

Yes No

Do you suffer from Bleeding or blood disorders (haemophilia, easily bruising)?

Yes No

Do you suffer from Stomach or bowel disease, ulcers/hiatus hernia/acid reflux?

Yes No

Do you suffer from Any infectious diseases (e.g. Hepatitis, HIV, TB)?

Yes No

Please add further details/information

Have you ever had Rheumatic fever, heart murmur or chorea?

Yes No

Have you ever had Liver disease (e.g. jaundice, hepatitis)?

Yes No

Have you ever had Kidney disease?

Yes No

Have you ever had Any other serious illness?

Yes No

Have you ever had Blood refused by the Blood Transfusion Service?

Yes No

Have you ever had A bad reaction to general or local anaesthetic?

Yes No

Have you ever had A joint replaced or another implant/s?

Yes No

Have you ever had Treatment that required you to be in hospital?

Yes No

Have you ever had Heart surgery?

Yes No

Have you ever had Brain surgery?

Yes No

Have you ever had Growth hormone treatment?

Yes No

Have you ever had A close relative with Creutzfeldt Jakob Disease (CJD)?

Yes No

Have you ever had steroid treatment?

Yes No

Further Details on Medical Background

How many units of alcohol do you drink per week? (1 unit = 1/2 pint of lager, a small glass of wine, a single measure of spirit)

0 units 1-2 units 3-5 units 6-9 units 10+ units

Do you smoke any tobacco products?

Yes No

Do you chew tobacco, pan, use gutkha or supar?

Yes No

If applicable, indicate amount smoked e.g. times per day

Please provide any other details which your dentist might need to know about

Our dental practice is bound by the General Data Protection Regulation (GDPR) 2018

I consent for the details provided to be used:

• Within the practice for the purposes of clinical care

I Accept

• With dental or medical colleagues outside the practice such as anaesthetists, dental or medical colleagues, scanning centres, dental laboratories and other third parties directly involved with or advising on my clinical care.

I Accept

Please note that answering "No" to any of the above will mean that we are unable to accept you as a patient

Consent for use of clinical data for treatment

I Accept

As part of your treatment, we may take photographs or videos of your treatment
Images may be also be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK and abroad.

Please indicate how we may be able to use any of your treatment images/videos?

Consent for use of clinical images and videos

I consent to all images being used anonymously I consent to all images being used anonymously apart from those where a substantial or identifiable part of my face is shown I do not consent to any images being used outside the purposes of my clinical care

Who completed this form

Self Parent Guardian Dentist Other

Signature of person filling out the form

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Online Medical History Form

Our dental practice is bound by the General Data Protection Regulation (GDPR) 2018

Consent for use of clinical images and videos

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