Registration and Confidential Medical HistoryPlease note, it is important that the forms are completed the day before your appointment. 1Patient Registration2Medical History Full Name* Please SelectMrMrsMissMsDrProf.Rev. Prefix First Last Date of Birth* Day Month YearSex* Male FemaleAddress* 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 Passing by Internet Recommended by friend/family member How long is it since you saw a dentist?Are you happy with the appearance of your teeth?* Yes NoAre facial aesthetics treatments something you may be interested in?* Yes NoDo you smoke any tobacco products now (or did you in the past)?* Never Used to YesHow 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 YesHow 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 NoHow 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 + unitsDo you take any prescribed medications or tablets from your Doctor (e.g tablets, ointments, injections or inhalers)?* Yes NoEnter your medications below or provide a written list of recent prescriptions*Do you have any allergies?*(particularly to medications, foods or materials) Yes NoPlease provide details:*Are you, or is there a possibility that you are pregnant?* Yes NoDue 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 NoPlease tick appropriate* High blood pressure Angina Valve replacement Heart attack Pacemaker Heart surgery Endocarditis OtherEnter details:*Lung, chest or breathing problems (such as bronchitis, asthma etc):* Yes NoPlease tick appropriate* Asthma COPD Bronchitis OtherEnter details:*Stomach, bowel, abdominal problems:* Yes NoPlease tick appropriate* Ulcer Crohn’s IBS OtherEnter details:*Skin conditions:* Yes NoPlease tick appropriate* Psoriasis Eczema Dermatitis OtherEnter details:*Have you got Diabetes* Yes NoPlease tick appropriate* Type I Type II Controlled with: diet Controlled with: medicationMental health problem:* Yes NoPlease tick appropriate* Depression Dementia ADHD OtherEnter details:*Neurological problems:* Yes NoPlease tick appropriate* MS ME Trigeminal neuralgia OtherEnter details:*Organ problems:* Yes NoPlease tick appropriate* Liver Kidney Thyroid Pancreas OtherEnter details:*Autoimmune problems:* Yes NoPlease tick appropriate* Sjorgren’s Rheumatoid conditions OtherEnter details:*Bone or joint problems:* Yes NoPlease tick appropriate* Arthritis Osteoporosis Gout OtherEnter details:*Blood borne infections:* Yes NoPlease tick appropriate* Hepatitis B Hepatitis C HIV OtherEnter details:*Blood clotting problems:* Yes NoPlease tick appropriate* DVT Stroke Warfarin treatment OtherEnter details:*Steroid treatment in the last two years?* Yes NoWhy?*Cancer:* Yes NoPlease tick appropriate* Breast Prostate Bowel Skin Mouth OtherEnter details:*When was it diagnosed?* MM slash DD slash YYYY Treatment:* Surgery Chemo Radio OngoingDo you carry a medical warning card?* Yes NoFor what reason?*Have you been hospitalised in the last six months?* Yes NoDetails (what for and when):*Have you ever had a bad reaction to general/local anaesthetic or sedation?* Yes NoIs there any reason why you cannot recline fully in the dental chair?* Yes NoEver get cold sores?*Always let us know if you have an active cold sore. Yes NoProblems with:* Epilepsy Seizures or fits Blackouts Giddiness Fainting attacks Other NoneHow often?*Date of last?* DD slash MM slash YYYY Are you attending or receiving treatment from a doctor, hospital clinic or specialist?* Yes NoEnter details*Is there any other aspect of your health or history that you feel we should be aware of?* Yes NoEnter details*Completed By* Self Parent GuardianSignature*(Self or parent/guardian)EmailThis field is for validation purposes and should be left unchanged.
