Registration and Confidential Medical History - Dental Touch Bristol

Registration and Confidential Medical History

Please note, it is important that the forms are completed the day before your appointment.

1Patient Registration

2Medical History

Company
This field is for validation purposes and should be left unchanged.
Full Name*
Prefix First Last
Date of Birth*
Day
Month
Year
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City ZIP / Postal Code
Mobile number*
Home number
Email*
Enter Email Confirm Email
NHS Number*
Occupation*
Ethnicity*
BMI
If known
GP Surgery Name, Address & Phone Number*
How did you hear about us?
- Leaflet/ Advert
- Social Media
- Passing by
- Internet
- Recommended by friend/family member

How long is it since you saw a dentist?
Are you happy with the appearance of your teeth?*
- Yes
- No
Are facial aesthetics treatments something you may be interested in?*
- Yes
- No
Do you smoke any tobacco products now (or did you in the past)?*
- Never
- Used to
- Yes
How much per day?*
Quit Date*
Please select a estimate of the date you quit smoking
DD slash MM slash YYYY
Do you chew tobacco, pan or gutkha or supari now (or did you in the past)?*
- Never
- Used to
- Yes
How much per day?*
Quit Date*
Please select a estimate of the date you quit smoking
DD slash MM slash YYYY
Do you drink alcohol?*
- Yes
- No
How many units of alcohol do you drink per week?*
(14 units = 7 pints of beer, 4 large glasses of wine)
- 0 - 5 units
- 6 - 10 units
- 11 - 14 units
- 14 + units
Do you take any prescribed medications or tablets from your Doctor (e.g tablets, ointments, injections or inhalers)?*
- Yes
- No
Enter your medications below or provide a written list of recent prescriptions*
Do you have any allergies?*
(particularly to medications, foods or materials)
- Yes
- No
Please provide details:*
Are you, or is there a possibility that you are pregnant?*
- Yes
- No
Due date
DD slash MM slash YYYY
Please indicate (and provide details) if you have had any of the following medical problems:
Heart and circulation problems:*
- Yes
- No
Please tick appropriate*
- High blood pressure
- Angina
- Valve replacement
- Heart attack
- Pacemaker
- Heart surgery
- Endocarditis
- Other
Enter details:*
Lung, chest or breathing problems (such as bronchitis, asthma etc):*
- Yes
- No
Please tick appropriate*
- Asthma
- COPD
- Bronchitis
- Other
Enter details:*
Stomach, bowel, abdominal problems:*
- Yes
- No
Please tick appropriate*
- Ulcer
- Crohn’s
- IBS
- Other
Enter details:*
Skin conditions:*
- Yes
- No
Please tick appropriate*
- Psoriasis
- Eczema
- Dermatitis
- Other
Enter details:*
Have you got Diabetes*
- Yes
- No
Please tick appropriate*
- Type I
- Type II
- Controlled with: diet
- Controlled with: medication
Mental health problem:*
- Yes
- No
Please tick appropriate*
- Depression
- Dementia
- ADHD
- Other
Enter details:*
Neurological problems:*
- Yes
- No
Please tick appropriate*
- MS
- ME
- Trigeminal neuralgia
- Other
Enter details:*
Organ problems:*
- Yes
- No
Please tick appropriate*
- Liver
- Kidney
- Thyroid
- Pancreas
- Other
Enter details:*
Autoimmune problems:*
- Yes
- No
Please tick appropriate*
- Sjorgren’s
- Rheumatoid conditions
- Other
Enter details:*
Bone or joint problems:*
- Yes
- No
Please tick appropriate*
- Arthritis
- Osteoporosis
- Gout
- Other
Enter details:*
Blood borne infections:*
- Yes
- No
Please tick appropriate*
- Hepatitis B
- Hepatitis C
- HIV
- Other
Enter details:*
Blood clotting problems:*
- Yes
- No
Please tick appropriate*
- DVT
- Stroke
- Warfarin treatment
- Other
Enter details:*
Steroid treatment in the last two years?*
- Yes
- No
Why?*
Cancer:*
- Yes
- No
Please tick appropriate*
- Breast
- Prostate
- Bowel
- Skin
- Mouth
- Other
Enter details:*
When was it diagnosed?*
MM slash DD slash YYYY
Treatment:*
- Surgery
- Chemo
- Radio
- Ongoing
Do you carry a medical warning card?*
- Yes
- No
For what reason?*
Have you been hospitalised in the last six months?*
- Yes
- No
Details (what for and when):*
Have you ever had a bad reaction to general/local anaesthetic or sedation?*
- Yes
- No
Is there any reason why you cannot recline fully in the dental chair?*
- Yes
- No
Ever get cold sores?*
Always let us know if you have an active cold sore.
- Yes
- No
Problems with:*
- Epilepsy
- Seizures or fits
- Blackouts
- Giddiness
- Fainting attacks
- Other
- None
How often?*
Date of last?*
DD slash MM slash YYYY
Are you attending or receiving treatment from a doctor, hospital clinic or specialist?*
- Yes
- No
Enter details*
Is there any other aspect of your health or history that you feel we should be aware of?*
- Yes
- No
Enter details*
Completed By*
- Self
- Parent
- Guardian
Signature*
(Self or parent/guardian)