Registration and Confidential Medical History Please note, it is important that the forms are completed the day before your appointment. 1Patient Registration2Medical History Full Name* Please SelectMrMrsMissMsDrProf.Rev. 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 numberEmail* Enter Email Confirm Email Occupation*Please select your occupationAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceDentistDoctorEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailRetiredSalesScience/ResearchSkilled LabourStay at home mumTechnologyTelecommunicationsTransportation/LogisticsOtherEthnicity*Please select your EthnicityWhite -English / Welsh / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerWhite - Any other White backgroundMixed / Multiple ethnic groups - White and Black CaribbeanMixed / Multiple ethnic groups - White and Black AfricanMixed / Multiple ethnic groups - White and AsianMixed / Multiple ethnic groups - Any other Mixed / Multiple ethnic backgroundAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAsian / Asian British - Any other Asian backgroundBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - CaribbeanBlack / African / Caribbean / Black British - Any other Black / African / Caribbean backgroundPrefer not to sayBMIIf knownGP Surgery Name, Address & Phone Number*How did you hear about us? Leaflet/ Advert 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 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)EmailThis field is for validation purposes and should be left unchanged.
