Online Medical History Form – Wellingborough Dental Surgery

01. Personal Details

First Name (required)

Last Name (required)

NHS Number

Date of birth (required)

Full Address (required)

Town (required)

Post Code (required)

Your Email Address (required)

Your Mobile Number (required)

Your Home Number

Preferred Method of Contact
SMS MobileEmailLetterPhone

Do you need a translator? (required)
NoYes

02. Emergency Contact Details

Full Name

DOB

Emergency Contact Tel

GP Surgery

GP Surgery Full Address

GP Surgery Postcode

03. Medical History (required)

Do you have, or have you had any of the following?

04. Lifestyle History

05. Females only

Are you pregnant? (required)

YesNoN/A

If yes, when is your baby due?

Are you breastfeeding?

YesNo

06. Signature

Please check below to certify that you have understood the above information and that your answers are accurate and up-to-date. Any incorrect information can be dangerous to your health, so please inform your dentist of any changes

I consent to receiving offers and promotions

YesNo

I consent to the practice sharing my information with other third parties in relation to my health care for example NHS referral system (GDPR)

YesNo

I am the: (required)

PatientParentGuardian

Consent Date (required)

Medical History Form

01. Personal Details

First Name (required)

Last Name (required)

NHS Number

Date of birth (required)

Full Address (required)

Town (required)

Post Code (required)

Your Email Address (required)

Your Mobile Number (required)

Your Home Number

Preferred Method of Contact SMS MobileEmailLetterPhone

Do you need a translator? (required) NoYes

02. Emergency Contact Details

Full Name

DOB

Emergency Contact Tel

GP Surgery

GP Surgery Full Address

GP Surgery Postcode

03. Medical History (required)

Anaemia

Arthritis

Artificial Joints/ Heart Valves

Bleeding Problems

Bone Problems (e.g. Osteoporosis)

Cancer

Chest Problems (e.g. Asthma/ COPD)

Chemotherapy/ Radiotherapy

Coldsores

Diabetes

Epilepsy/Seizures/Fits

Heart Problems (e.g. Heart Attack)

High/ Low Blood Pressure

HIV/ AIDS

Kidney Problems

Liver Problems (e.g. Hepatitis)

Mental Health Issues

Organ Transplant

Rheumatic Fever/Infective Endocarditis

Stomach Problems (e.g. Reflux, IBS)

Stroke/ Mini Stroke

Surgery/ Operations

If you have ticked any of the above or if you feel anything else is medically relevant, then please provide further details in the space below

If you take any medication, please list them all in the space below:

If you have any allergies, please list them all in the space below:

04. Lifestyle History

Do you smoke? (required)

If yes, what do you smoke?

How many do you smoke a day?

How many years have you smoked for?

Do you drink alcohol (required)

If yes, how many units on average per week do you drink? (Pint = 2 Units, Bottle of Wine = 9 Units, Glass of Wine = 1 or 2 units, Can of beer/Lager/Cider = 2 Units, Single Spirit = 1 Unit, Alcopop = 1.5 Units)

Have you ever been dependant on drugs? (required)

If yes, please provide more detail

05. Females only

Are you pregnant? (required)

If yes, when is your baby due?

Are you breastfeeding?

06. Signature

I consent to receiving offers and promotions

I consent to the practice sharing my information with other third parties in relation to my health care for example NHS referral system (GDPR)

I am the: (required)

Consent Date (required)

Preferred Method of Contact
SMS MobileEmailLetterPhone

Do you need a translator? (required)
NoYes

If you have ticked any of the above or if you feel anything else is medically relevant, then please provide
further details in the space below

If yes, how many units on average per week do you drink? (Pint = 2 Units, Bottle of Wine = 9 Units, Glass of Wine = 1 or 2 units, Can of beer/Lager/Cider = 2 Units,
Single Spirit = 1 Unit, Alcopop = 1.5 Units)