Medical
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Medical history form

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Banbeath Dental Practice

1 Banbeath Court, Leven, KY8 5GY

01333 423775

Monday - Friday
8.00am - 12.00pm & 1.00pm - 5.00pm

Banbeath Dental Practice is the trading name of Esme Headen Ltd CO No SC474324

Banbeath Dental Practice

1 Banbeath Court, Leven, KY8 5GY

01333 423775

Monday - Friday
8.00am - 12.00pm & 1.00pm - 5.00pm

Banbeath Dental Practice is the trading name of Esme Headen Ltd CO No SC474324

Banbeath Dental Practice

1 Banbeath Court, Leven, KY8 5GY

01333 423775

Monday - Friday
8.00am - 12.00pm & 1.00pm - 5.00pm

Banbeath Dental Practice is the trading name of Esme Headen Ltd CO No SC474324

2021 Banbeath Dental Practice

2021 Banbeath Dental Practice

Personal details
Title: ^*			Full name: ^*
Date of birth: ^*			Occupation: ^*
Address: ^*
Home phone:			Mobile phone:
Work phone:			Email address:
Please state preferred method of contact: ^*			When was your last dental treatment?: ^*

Are you...	Yes	No	If yes, please give details
Taking any prescribed medication? (e.g. tablets, ointments or inhalers - including immunosuppressants, contraceptives, HRT or blood thinners) If you have a repeat prescription, please hand to a member of staff to copy. ^*
Receiving or have received treatment for cancer? (chemotherapy/radiotherapy) ^*
Allergic to any medicine or substances? (e.g. penicillin, latex, rubber or food) ^*
Attending or receiving treatment from a doctor, hospital, clinic or specialist? ^*
Currently or possibly pregnant? ^*
Carrying a warning card for any reason? ^*

Have you...	Yes	No	If yes, please give details
Suffered from heart problems - including angina, blood pressure or heart attack? ^*
Ever had heart surgery or a pacemaker fitted? (Please give date if possible) ^*
Suffered from a blood disorder? (haemophilia/anaemia) ^*
Had blood refused from a blood transfusion service? ^*
Suffered from bruising or persistent bleeding after a tooth extraction? ^*
Suffered from, or has anyone in your family suffered from diabetes? (if so Type I/Type II) ^*
Suffered from liver disease? (e.g. hepatitis/jaundice) ^*
Suffered from bone or joint disease? (e.g. osteoporosis) ^*
Suffered from bronchitis/asthma or other chest conditions? ^*
Suffered from fainting attacks/giddiness/epilepsy/blackouts? ^*
Ever had a bad reaction to local or general anaesthetic? ^*
Ever had to be hospitalised? ^*

Do you...	Yes	No	If yes, please give details
Smoke any tobacco products or have done in the past? (If so, how many per day & for how long) ^*
Vape? ^*
Chew tobacco? ^*
Drink alcohol - if so, how many units per week? (1 unit of alcohol is a half pint of lager, a single measure of spirits or a single glass of wine) ^*
Use any self-prescribed drugs or non-prescription drugs? (e.g. street drugs, aspirin etc.) ^*
Weigh more than 21 stone / 135kg? ^*

		01333 423775	DENTAL EMERGENCY?

Emergency contact
Name: ^*		Number: ^*

Please use this space below for any additional information

Sign and date here
Signed: ^*	(clear)	Date: ^*