Patient Medical Form - Beech House Dental Practice

Personal Information

Title:

Last Name:

Preferred Name:

First Name:

Date of birth:

Sex:

Male:

Female:

How did you hear about the practice?

Address

Address Line 1:

Address Line 2:

Postcode:

Contact details

Telephone:

Mobile:

Email:

Occupation:

In the Event of an emergency please contact

Name:

Telephone:

Relationship to you:

Doctor's details

Name:

Telephone:

Address Line 1:

Address Line 2:

Postcode:

Completed By

Self:

Parent:

Guardian:

Other:

Other detail:

Have you ever had

Alcohol

How many units of alcohol do you consume (one unit is 1/2 glass of wine or 1/3 pint of beer)?

Smoking

Do you smoke or chew any tobacco-products (or did you in the past)?

Yes: No:

Please give details:

Do you vape/use electronic cigarettes (or did you in the past)?

Yes: No:

Please give details:

Please give any other details which your dentist might need to know about, such as self prescribed medications or any disabilities or health concerns you may have.

Are you currently?

Receiveing treatment from a doctor, hospital or clinic?

Yes: No:

Please give details:

Taking or previously taken Biphosphonates (oral or IV) eg alendronic acid, prolia?

Yes: No:

Please give details:

Taking any other prescribed medicines, other tablets, ointments, injections or inhalers including contraceptives and hormone replacement therapy?

Yes: No:

Please give details:

Carrying a medical warning card?

Yes: No:

Please give details:

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Have an emergency?