Medical History - Busby House Dental Centre

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Medical History

Please complete all required fields!

Surname*

Please enter your name

Forename*

Please enter your first or given name

Please tick appropriate box. If you have further details, including any allergies or pills, tablets or other medication that you take, please enter them in the ‘Further Details’ box.

Are you aware of anything that you are allergic to? (penicillin or another antibiotic, pollen, latex, food, jewellery or any other substance)*

YES NO UNSURE Please answer this question

Have you ever had any heart problems/conditions? (blood pressure problems, angina or chest pains, pacemaker or any other heart or blood vessel condition)*

YES NO UNSURE Please answer this question

Have you ever had any chest or breathing problems/conditions? (asthma, bronchitis or any other breathing problems)*

YES NO UNSURE Please answer this question

Have you ever had any stomach, gut, liver or kidney problems/conditions?*

YES NO UNSURE Please answer this question

Do you have any blood or bleeding problems/conditions?*

YES NO UNSURE Please answer this question

Do you have any blood or bleeding problems/conditions?Are you prone to fits/faints or do you have epilepsy?*

YES NO UNSURE Please answer this question

Do you have any problems or conditions relating to your bones, joints or muscles? (arthritis, muscle weakness or any other condition)*

YES NO UNSURE Please answer this question

Do you have hepatitis, HIV, AIDS or tuberculosis (TB)?*

YES NO UNSURE Please answer this question

Do you have hepatitis, HIV, AIDS or tuberculosis (TB)?Are you pregnant or is there a possibility you could be pregnant?*

YES NO UNSURE Please answer this question

Do you have diabetes?*

YES NO UNSURE Please answer this question

Do you have a medical condition or problem not specified above?*

YES NO UNSURE Please answer this question

Do you have a medical condition or problem not specified above?Are you currently under treatment from a doctor, consultant or clinic?*

YES NO UNSURE Please answer this question

Do you carry a medical warning card?*

YES NO UNSURE Please answer this question

Are you taking or meant to take medicine prescribed by your doctor or otherwise? (tablets, pills, patches, medicines, inhalers, ointments, injections, oral contraceptives, herbal remedies, recreational drugs, recent vaccinations). If yes, please enter them in the ‘Further Details’ box below*

YES NO UNSURE Please answer this question

Are there any conditions that run in your family? (diabetes, sickle cell disease or any other conditions). If yes, please enter them in the ‘Further Details’ box below.*

YES NO UNSURE Please answer this question

Have you ever had an illness or operation that required hospital treatment? If yes, please enter them in the ‘Further Details’ box below.*

YES NO UNSURE Please answer this question

Have you ever had an illness or operation that required hospital treatment? If yes, please enter them in the ‘Further Details’ box below.*

Please select an option

Additional Requirements or Special Needs*

Visual Imparement
Communication Difficulties
Wheelchair User
Hearing Difficulties
Mental Health Difficulties

Hoist Transfer Required
Learning Difficulties
Physical Difficulty
None
Other (Please specify below)

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Details

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Further Details

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Name of Patient/ Parent or Carer*

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Sign Here*

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Date*

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Submit

13 Hagbourne Road,
Didcot,
Oxfordshire,
OX11 8DP.
01235 816 486
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Busby House Dental Centre Ltd trading as Busby House Dental Centre is an Appointed Representative of Financing First Limited, which is authorised and regulated by the Financial Conduct Authority. Busby House Dental Centre Ltd is a credit broker, not a lender. The provider of a payment scheme which is not offered through or by Financing First Limited may not be so authorised and regulated.

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