PARRYS LANE DENTAL PRACTICE - CONFIDENTIAL MEDICAL HISTORY UPDATE

SURNAME: DATE OF BIRTH: ADDRESS: FORENAME (S): OCCUPATION: POSTCODE: HOME: WORK: MOBILE: TITLE: M/F:

CONTACT TELEPHONE NUMBERS

DOCTOR'S NAME & ADDRESS:

ARE YOU: A nursing or expectant mother? (please give (due) date of birth) Receiving treatment from a doctor, hospital or clinic? Taking any medicines from your doctor? (please give complete list) Taking or have taken steroids in the last two years? Carry a warning card, SOS bracelet or similar? DO YOU SUFFER FROM: Allergies to any medicines (e.g. Antibiotics), substances (e.g. Latex) or food? Raised or low blood pressure? Hay fever or eczema? Epilepsy, blackouts or fainting attacks? Diabetes (or does anyone else in your family)? Arthritis or other joint conditions? Asthma or other chest conditions? Cold sores? Panic attacks? Bruising or persistent bleeding following a tooth extraction? Any infectious disease (including HIV & Hepatitis)? HAVE YOU EVER HAD: Heart disease or heart surgery? Rheumatic fever or cholera? Liver disease (eg. Jaundice, hepatitis)? Kidney disease? A bad reaction to a local or general anesthetic? A joint replacement? Do you smoke? (if yes, please state amount per day) Do you drink alcohol? (if yes, please state amount in units per week) Is there any other information we should be aware of? If yes, please give details

NO

YES

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Date:

Should any of the above information change, please inform us immediately Thank you for taking the time to complete this form.