Medical History Form

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Please Select^* :	Surname^*	First Name^*
Address^*		Postcode^*	Date of Birth^*
		Mobile^*
Email Address^*		Tel(Home)^*	Tel(Bus)^*
Emergency Contact/ Name and telephone^*
Name of Dental Insurance	Recommended by:	What is the purpose of your visit?

Do you feel very nervous about having dental treatment?	YESNO
Have you ever had a difficult tooth extraction?	YESNO
Have you ever stayed in hospital or had a operation?	YESNO
Are you allergic to any tablets or medicines?	YESNO
Do you smoke?	YESNO
Do you have an artificial hip, heart valve or other implant?	YESNO
Are you currently taking any medication?	YESNO
WOMEN
Are you pregnant?	YESNO
Are you currently taking the contraceptive pill?	YESNO

Are you happy with the appearance of your teeth?	YESNO
Who is your medical doctor?