Medical History Form – JacMe Oral Care

Patient

Title: Last Name: First Name: Tel:

Address: Email Address: Date of birth:

Occupation: Sex (please circle): Male Female

Name of Next of Kin: Relationship: Address:

Tel:

Doctor’s Details

Doctor’s Name: Doctor’s Address:

Doctor’s Tel:

Are you currently, or do you suffer from? Yes No Details Did you, as a child or since, have? Yes No Details

Pregnant? Blood refused by Blood Transfusion Service?

Taking prescribed medicines? Bad reaction to anaesthetic?

Carrying a medical warning card? Joint replacement or implant?

Allergies to any medicines/foods/contact Been hospitalised?

Hayfever or eczema? Heart surgery?

Bronchitis, asthma or chest infections? Brain surgery?

Fainting attacks i.e. epilepsy? Growth hormone treatment?

Muscle problems? Family with Creutzfeldt Jakob Disease?

Heart problems? Steroid disease?

Diabetes? Drinking

Neurological diseases? How many units of alcohol do you drink per week?

Arthritis? Smoking and Chewing Yes No In the past

Bruising after tooth extraction or surgery? Do you smoke or chew any tobacco products?

Any infectious diseases? Please provide any other relevant information which we should know of:

Stomach ulcers?

Liver disease? Form completed by (please circle): Self Parent Guardian Dentist

Kidney disease? Patient Signature: Date:

Any other serious illness? Dentist Signature: Date:

 Medical History Form – JacMe Oral Care

Please check that the health information on this form is still correct (including information on smoking and drinking). If not, please amend as necessary or note any changes
below.

Date No Change List any changes below Patient’s signature