Over 18yrs Old - Dental On Mahoe

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

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

6 + 4 =