Confidential Medical History Form - Blackburn Orthodontics Orthodontics

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53 James Street, Blackburn, BB1 6BE
Tel: 01254 261 161

Confidential Medical History Form

We ask you for information about your general health to help us treat you safely. Please fill the form below with your contact details, answer the health questions and then sign the form. We will use this form during later visits to discuss any changes in general health. All information will be kept strictly confidential by the people caring for you.

Title

Surname

Forename

Date of Birth

Sex

MaleFemale

Forename

Address Line 1

Address Line 2

Postcode

Telephone Number (home)

Mobile Number

Emaila valid email

Occupation

In the event of an emergency, please contact:

Name

Telephone Number

Relationship to you

Doctor's Details:

Doctor's Name

Address Line 1

Address Line 2

Postcode

Telephone number

Are you currently:

Receiving treatment from a doctor, hospital or clinic?

YesNo

Give Details:

0 /

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

YesNo

Give Details:

0 /

Carrying a medical warning card?

YesNo

Give Details:

0 /

Pregnant or possibly pregnant?

YesNo

Give Details:

0 /

Have you ever suffered from:

Allergies to medicines (eg penicillin), substances (eg latex/rubber) or foods?

YesNo

Give Details:

0 /

Bronchitis, asthma or other chest condition?

YesNo

Give Details:

0 /

Fainting attacks, giddiness, blackouts, epilepsy?

YesNo

Give Details:

0 /

Heart Problems, angina, blood pressure problems, or stroke?

YesNo

Give Details:

0 /

Diabetes (or does any one in your family)?

YesNo

Give Details:

0 /

Bone or joint disease?

YesNo

Give Details:

0 /

Bruising or persistent bleeding following injury, tooth extraction or surgery?

YesNo

Give Details:

0 /

Liver disease (eg jaundice, hepatitis) or kidney disease?

YesNo

Give Details:

0 /

Any other serious illness or infectious disease?

YesNo

Give Details:

0 /

Blood refused by the Blood Transfusion Service?

YesNo

Give Details:

0 /

A bad reaction to general or local anaesthetic?

YesNo

Give Details:

0 /

Treatment that requıres you to be in hospital?

YesNo

Give Details:

0 /

Heart surgery?

YesNo

Give Details:

0 /

Alcohol

How many units of alcohol do you drink per week? (A unit is half a pint of lager, a single measure of spirits or a single glass of wine/aperitif).

units of alcohol

Smoking

Do you smoke any tobacco products now (or did you in the past)

YesNo In the past

times per day

Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)

YesNo In the past

times per day

Please give any details which your dentist might need to know about, such as self-prescribed medicine (eg aspirin) or any disabilities you may have.

0 /

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READY TO SMILE?

Please get in touch on email
if you would like to book or discuss an initial FREE consultation to find out more about the clear aligners and other treatments available at our practice in Blackburn.

Dedicated team that provides the best dental care in the area

We are open to any questions, use one of the forms of contact and we will try to answer as soon as possible.

Treatments

Contact Details

01254 261 161

Email us

53 James Street, Blackburn, BB1 6BE

READY TO SMILE?

Please get in touch on email if you would like to book or discuss an initial FREE consultation to find out more about the clear aligners and other treatments available at our practice in Blackburn.

Treatments

Contact Details

Please get in touch on email
if you would like to book or discuss an initial FREE consultation to find out more about the clear aligners and other treatments available at our practice in Blackburn.