Adult Patient Form First Name Last Name Date of Birth: Home address: Postcode: Email address Home phone: Mobile: Work Phone Occupation Emergency contact person Phone Number Medical Doctors Name Phone 1. Are you receiving any medical treatment at the present time? Yes No Details 2. Are You taking any medicines, tablets, capsules or drugs ? If so please list. Yes No Details: 3. Have you experienced any allergies or unusual effects from any tablets, drugs, injections, Anaesthetic or latex? Yes No Details: 4. Have you ever had any of the following? If so please tick as appropriate Rheumatic Fever Heart Surgery High Blood Pressure Stroke Arthritis Hepatitis-Specify type A,B,C Bronchitis or Chest Problems Asthma Epilepsy Anaemia Diabetes Kidney Trouble Gastric Problems Cold Sores Depressive Illness Severe Headaches Have you ever been given or currently taking medication for cancer involving bone? Yes No Have you ever been given or are currently taking the drug Fosamax? Yes No Have you had any prosthetic surgery? (eg heart valve or Hip Replacement) Yes No Details Women: Are you Pregnant? If So, how many months Yes No Are you HIV positive? Yes No Are you at risk of HIV exposure? Yes No Do you Smoke Yes No Are there any other aspects concerning your health that you think we should know about? Yes No Name of last Dentist Approximate date of last dental visit Do you have Dental pain or a Dental Problem at present? Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches? Yes No Do you become anxious or uncomfortable when you are having dental treatment? Yes No How did you hear about us? Sign:Patient to sign here or legal gaurdian or representative Relationship to Patient Youth Patient Form First Name Last Name Date of Birth: Home address: Postcode: Email address Home phone: Parent Mobile: Childs Mobile Occupation Emergency contact person Phone Number Family Doctors Name Phone Are you Presently receiving any medical Treatment? Yes No Have you any allergies that you are aware of? Yes No Have you ever experienced excessive bleeding form dental treatment, cuts or scratches? Yes No Have you ever experienced excessive bleeding form dental treatment, cuts or scratches? Yes No Have you ever experienced excessive bleeding form dental treatment, cuts or scratches? Rheumatic fever High Blood pressure Arthritis Bronchitis Severe headaches Epilepsy Gastric Problems Depressive Illness Tuberculosis Heart Trouble Asthma Hepatitis Chest pains Thyroid Problem Anaemia Kidney trouble Cold sores Drug dependence Please Provide details: Have you ever taken long term medications? Yes No If yes please list Have you any allergies to medicines? Yes No If yes please list Have you any allergies to medicines? Yes No If yes please list Do you have any artificial Joints? Eg hip joint Yes No Have you ever had contact with the AIDS virus or Hepatitis B virus? Yes No Have you ever had a reaction to an anaesthetic? Yes No Are you Pregnant now? Yes No If yes, how many weeks? Are there any other aspects concerning your health that you think we should know about? Yes No If yes Please indicate Are you currently taking any drugs or medicines? Yes No Does your jaw ‘click’ or hurt Yes No Does your jaw ‘click’ or hurt Yes No Do you think you have occasional bad breath Yes No Do you think you have occasional bad breath Yes No Do you Smoke Yes No Additional information: Signed Patient/Parent/ Guardian
