Confidential Medical History Form

Confidential Medical History Form2023-03-02T15:45:01+00:00

Patient information

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Dentist and Doctor information

Have you been treated by your family doctor or a medical specialist for illnesses in the past year? *

Medical History

Do you have or have you had any of the following (please give details where appropriate):

Have you been told by your doctor that you need to take antibiotics before dental procedures? *
Are you allergic to any antibiotics? *
Rheumatic fever / congenital heart defect / bacterial endocarditis *
Heart Problems / angina / arrhythmia / heart attack / heart valve problems / history of cardiac surgery *
Circulatory problems / high blood pressure / stroke / transient ischaemic attack *
A history of bleeding problems or blood disorders in the family *
Chest Trouble / breathing difficulty / asthma / emphysema / bronchitis / pneumonia *
Diabetes controlled by insulin (Type I) or oral medication (Type II) *
Fainting attacks / giddiness / epilepsy / fits / memory loss *
Stomach or bowel disease / gastric or duodenal ulcer / hiatus hernia / acid reflux or regurgitation *
IBS or Coeliac disease *
Renal (kidney) disease / need for dialysis *
Liver or gall bladder disease including hepatitis / cirrhosis / jaundice / gallstones *
A transplanted organ or immunosuppressive drugs *
Hormonal imbalance / endocrine / thyroid / parathyroid / pituitary / adrenal gland disease *
Skin problems / eczema / psoriasis / herpes simplex (cold sores) / delayed healing / keloid formation *
Bone or joint disorders / fractures / osteoporosis / arthritis / ankylosing spondylitis *
Headaches / migraines / jaw pain / photophobia / neck pains *
Psychiatric disorders *
Neurological disorders requiring medication / atypical facial pain / trigeminal neuralgia *
Eating disorders / anorexia / bulimia / history of vomiting *
Malignant disease (cancer) that required surgery, chemotherapy and / or radiotherapy *
Eye problems / glaucoma / loss of vision / cataract / previous eye surgery *
Autoimmune disease / rheumatoid arthritis / lupus / multiple sclerosis / fibromyalgia / Guillain-Barré *
Any artificial prosthesis (such as heart valve, pacemaker, implantable defibrillator or joint replacement) *
Sexually transmitted infection / herpes simple (HSV) / papilloma (HPV) (warts) *
Are you a carrier or any of the following blood borne diseases: HIV, Hepatitis B, Hepatitis C *
Have you been abroad or visited a country on the UK governments HCID (High Consequence Infectious Disease) list? *

Do you take or have you ever taken the following medication?

Steroid medication including tablets, creams or ointments *
Antiplatelet or anticoagulant medication *
Bisphosphonates (eg Fosamax/ Actonel) or Denosumab (Xgeva or Prolia) for osteoporosis or bone disease in the last 10 years *
Are you pregnant? *
Are you currently breastfeeding *
Do you smoke/vape, or have you ever smoked/vaped or used other tobacco products? *
How many units of alcohol do you consume per week? *

Sleep Assessment

Certain health conditions may be related to a disturbance in your sleep. This may have an impact on the orthodontic treatment. Please answer the following sleep-related questions.

Breathing problems during sleep / sleep apnoea / snoring / periodic wakening / tiredness on waking *
Sitting and reading *
Watching TV *
Sitting, inactive in a public place (e.g. a theatre or a meeting) *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon when circumstances permit *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in the traffic *

Smile Questionnaire

To be filled out by new patients.
What are your main concerns for seeking dental treatment?

Aesthetically
Dental Health
Function
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Dr Asif Chatoo with patient
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