25-27 Chertsey Street

Guildford Surrey GU1 4HD

Call us today on

01483 504705

Online Medical History Form

This provides the dentist with important information required for your Dental treatment and Oral Health Care. All information given will be kept strictly confidential by the people caring for you.

Please fill out all fields

Patient Details
Title:
Forename:
Surname:
Address:
Postcode:
D.O.B:
Home Phone:
Mobile Phone:
Occupation:
Email Address:
We would like to contact you in the future with newsletters & special offers. Please let us know if you do not wish to receive this type of email correspondence.

Emergency contact details:
Name:
Phone Number:
Relationship:
We would like to contact you in the future with newsletters & special offers. Please let us know if you do not wish to receive this type of email correspondence.

Medical History:
Are you currently receiving any medical treatment from a doctor, hospital or clinic?	Yes No
Are you currently taking any prescribed medicines, inhalers, injections or tablets?	Yes No
Do you carry a medical warning card?	Yes No
Have you suffered any allergies to medicines, substances or foods? i.e. Penicillin or Latex	Yes No
Are you, or have you been, under the care of a doctor during the past two years?	Yes No
Have you ever had any of the following? If so, please tick as appropriate	Rheumatic Fever Heart problems/Angina High Blood Pressure/Stroke Bronchitis/Asthma/Other chest conditions Hepatitis A Hepatitis B Hepatitis C Epilepsy/Blackouts/Giddiness/Fainting Bone/Joint Disease Diabetes (or any close family member) Liver/Kidney Disease Any other serious illness or disease
Have you had any prosthetic surgery? (E.g. Heart Valve or Hip Replacement)	Yes No
Are you pregnant or possibly pregnant?	Yes No
Have you ever had your blood refused by the Blood Transfusion Service?	Yes No
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?	Yes No
How many units of alcohol do you drink a week?	(One unit is a half a pint of lager, a single measure of spirits or a small glass of wine/aperitif)
Do you smoke any tobacco products now, or in the past?	Yes No In the past
Do you chew tobacco, pan, use gutkha or supari now or in the past?	Yes No In the past

Additional Details:
Please give any other details which your dentist might need to know about, such as self-prescribed drugs (e.g. aspirin) or any disabilities you may have:
Medical Doctor's Name:
Doctor's Telephone Number:
Practice Address:
Doctor's Postcode:

We want to ensure all your dental needs are met. Please indicate if you have any concerns with any of the following:

Sign-off:
Completed by:	Self Parent Guardian
We are interested to find out how our new patients find our practice. Please kindly indicate how you found us below:

Root Canal Treatment

Our exceptional dental care protects and preserves your teeth.

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Gum Problems

We’re here to help - whether you simply want to maintain your teeth or have a specific dental concern.

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Dental Implants

Missing teeth? We can fill in the gaps with our long-lasting, natural-looking implants.

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Teeth Straightening

Set things beautifully straight with our affordable orthodontic options.

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Teeth Whitening

Brighten up lacklustre teeth with safe, effective whitening.

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Cosmetic Dentistry

Want to smarten up your smile? Take your pick from our collection of cosmetic treatments.

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Family Dentistry

Ensure your family’s long term dental health with our extensive range of dental services.

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Hygienist

Our friendly hygienists can deep clean your teeth and teach you how to look after them too!

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Specialist Dental

25-27 Chertsey Street,

Guildford, Surrey GU1 4HD

Tel: 01483 504705

email: info@specialistdental.co.uk

My teeth are sensitive:	Yes No
My dentures feel uncomfortable or loose:	Yes No
I am worried about the cost of treatment and how to pay:	Yes No
I would like to enhance my lips:	Yes No
I would like to reduce my lines and wrinkles:	Yes No
How important is keeping your teeth?	Please choose 1 being the lowest and 10 the highest
Where would you rate your current dental health:	Please choose 1 being the lowest and 10 the highest

I am self-conscious about my teeth when I smile:	Yes No
My teeth are not as bright and white as I would like them to be:	Yes No
I am unhappy about the colour of my crowns or fillings:	Yes No
Some of my teeth are chipped or misshapen:	Yes No
I have gaps that show:	Yes No
I wish I showed more of my teeth when I smile:	Yes No
I am concerned about my gums receding:	Yes No
I am concerned about bad breath:	Yes No
My gums bleed when I brush my teeth:	Yes No

Online Medical History Form

Root Canal Treatment

Gum Problems

Dental Implants

Teeth Straightening

Teeth Whitening

Cosmetic Dentistry

Family Dentistry

Hygienist

Get in touch with us today!

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