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

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:

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:
Yes No
Yes No
Yes No
Yes No
Yes No
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
Yes No
Yes No
Yes No
Yes No

(One unit is a half a pint of lager, a single measure of spirits or a small glass of wine/aperitif)

Yes No 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:

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

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Please choose 1 being the lowest and 10 the highest

Please choose 1 being the lowest and 10 the highest

Sign-off:
Self Parent Guardian
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