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

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)
Phone
This field is for validation purposes and should be left unchanged.