Patient Details

In the event of an emergency, please contact:

Doctor’s details:

Are you currently:

Receiving treatment from a doctor, hospital or clinic? Taking any prescribed medicines?
(eg tablets, ointments, injections or inhalers, including contraceptives and hormone replacement therapy) Carrying a medical warning card? Pregnant or possibly pregnant?

Have you ever suffered from:

Allergies to medicines (eg penicillin), substances (eg latex/rubber) or foods? Bronchitis, asthma or other chest condition? Fainting attacks, giddiness, blackouts, epilepsy? Heart problems, angina, blood pressure problems, or stroke? Diabetes (or does anyone in your family)? Bone or joint disease? Bruising or persistent bleeding following injury, tooth extraction or surgery? Liver disease (eg jaundice, hepatitis) or kidney disease? Any other serious illness or infectious disease?

Are you currently taking or have taken in the past:

Any medications designed to strengthen your bones?

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)

Smoking:

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

Completed by:

Please select who has completed this form Please give additional details relating to any of the options that have been selected as ‘Yes’, or details that your dentist might need to know about, such as self-prescribed medicines (eg aspirin) or any disabilities you may have:

Preventative Care Bridges Crowns Hygiene Services Root Canal Treatment Tooth Whitening Veneers Dentures Dental Implants IV Sedation Oral Surgery Contact Us

Medical History Form

Patient Details

In the event of an emergency, please contact:

Doctor’s details:

Are you currently:

Have you ever suffered from:

Are you currently taking or have taken in the past:

Alcohol:

Smoking:

Completed by:

first class, friendly and
caring dental service
in Cambridge

Send us a message

Medical History Form

Patient Details

In the event of an emergency, please contact:

Doctor’s details:

Are you currently:

Have you ever suffered from:

Are you currently taking or have taken in the past:

Alcohol:

Smoking:

Completed by:

first class, friendly and caring dental servicein Cambridge

Send us a message

first class, friendly and
caring dental service
in Cambridge