Registration and Confidential Medical History Please note, it is important that the forms are completed the day before your appointment. 1Patient Registration2Medical History CompanyThis field is for validation purposes and should be left unchanged.Full Name* Please SelectMrMrsMissMsDrProf.Rev. Prefix First Last Date of Birth* Day Month Year Sex* Male Female Address* Street Address Address Line 2 City ZIP / Postal Code Mobile number*Home numberEmail* Enter Email Confirm Email NHS Number*Occupation*Please select your occupationAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceDentistDoctorEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailRetiredSalesScience/ResearchSkilled LabourStay at home mumTechnologyTelecommunicationsTransportation/LogisticsOtherEthnicity*Please select your EthnicityWhite -English / Welsh / Scottish / Northern Irish / BritishWhite – IrishWhite – Gypsy or Irish TravellerWhite – Any other White backgroundMixed / Multiple ethnic groups – White and Black CaribbeanMixed / Multiple ethnic groups – White and Black AfricanMixed / Multiple ethnic groups – White and AsianMixed / Multiple ethnic groups – Any other Mixed / Multiple ethnic backgroundAsian / Asian British – IndianAsian / Asian British – PakistaniAsian / Asian British – BangladeshiAsian / Asian British – ChineseAsian / Asian British – Any other Asian backgroundBlack / African / Caribbean / Black British – AfricanBlack / African / Caribbean / Black British – CaribbeanBlack / African / Caribbean / Black British – Any other Black / African / Caribbean backgroundPrefer not to sayBMIIf knownGP Surgery Name, Address & Phone Number*How did you hear about us? Leaflet/ Advert Social Media Passing by Internet Recommended by friend/family member Other How long is it since you saw a dentist?Are you happy with the appearance of your teeth?* Yes No Are facial aesthetics treatments something you may be interested in?* Yes No Do you smoke any tobacco products now (or did you in the past)?* Never Used to Yes How much per day?*Quit Date*Please select a estimate of the date you quit smoking DD slash MM slash YYYY Do you chew tobacco, pan or gutkha or supari now (or did you in the past)?* Never Used to Yes How much per day?*Quit Date*Please select a estimate of the date you quit smoking DD slash MM slash YYYY Do you drink alcohol?* Yes No How many units of alcohol do you drink per week?*(14 units = 7 pints of beer, 4 large glasses of wine) 0 – 5 units 6 – 10 units 11 – 14 units 14 + units Do you take any prescribed medications or tablets from your Doctor (e.g tablets, ointments, injections or inhalers)?* Yes No Enter your medications below or provide a written list of recent prescriptions*Do you have any allergies?*(particularly to medications, foods or materials) Yes No Please provide details:*Are you, or is there a possibility that you are pregnant?* Yes No Due date DD slash MM slash YYYY Please indicate (and provide details) if you have had any of the following medical problems:Heart and circulation problems:* Yes No Please tick appropriate* High blood pressure Angina Valve replacement Heart attack Pacemaker Heart surgery Endocarditis Other Enter details:*Lung, chest or breathing problems (such as bronchitis, asthma etc):* Yes No Please tick appropriate* Asthma COPD Bronchitis Other Enter details:*Stomach, bowel, abdominal problems:* Yes No Please tick appropriate* Ulcer Crohn’s IBS Other Enter details:*Skin conditions:* Yes No Please tick appropriate* Psoriasis Eczema Dermatitis Other Enter details:*Have you got Diabetes* Yes No Please tick appropriate* Type I Type II Controlled with: diet Controlled with: medication Mental health problem:* Yes No Please tick appropriate* Depression Dementia ADHD Other Enter details:*Neurological problems:* Yes No Please tick appropriate* MS ME Trigeminal neuralgia Other Enter details:*Organ problems:* Yes No Please tick appropriate* Liver Kidney Thyroid Pancreas Other Enter details:*Autoimmune problems:* Yes No Please tick appropriate* Sjorgren’s Rheumatoid conditions Other Enter details:*Bone or joint problems:* Yes No Please tick appropriate* Arthritis Osteoporosis Gout Other Enter details:*Blood borne infections:* Yes No Please tick appropriate* Hepatitis B Hepatitis C HIV Other Enter details:*Blood clotting problems:* Yes No Please tick appropriate* DVT Stroke Warfarin treatment Other Enter details:*Steroid treatment in the last two years?* Yes No Why?*Cancer:* Yes No Please tick appropriate* Breast Prostate Bowel Skin Mouth Other Enter details:*When was it diagnosed?* MM slash DD slash YYYY Treatment:* Surgery Chemo Radio Ongoing Do you carry a medical warning card?* Yes No For what reason?*Have you been hospitalised in the last six months?* Yes No Details (what for and when):*Have you ever had a bad reaction to general/local anaesthetic or sedation?* Yes No Is there any reason why you cannot recline fully in the dental chair?* Yes No Ever get cold sores?*Always let us know if you have an active cold sore. Yes No Problems with:* Epilepsy Seizures or fits Blackouts Giddiness Fainting attacks Other None How often?*Date of last?* DD slash MM slash YYYY Are you attending or receiving treatment from a doctor, hospital clinic or specialist?* Yes No Enter details*Is there any other aspect of your health or history that you feel we should be aware of?* Yes No Enter details*Completed By* Self Parent Guardian Signature*(Self or parent/guardian)
