Receiving treatment from a doctor, hospital or clinic? *
Are you undergoing or have you had previous treatment for any cancers?(e.g. chemotherapy, radiotherapy, hormone therapy?) *
Taking any prescribed medicines? *
Please list medication here: *
Pregnant or possibly pregnant? *
Carrying a medical warning card? *
Allergies to any medications (e.g. penicillin) or substances (latex/rubber), acrylic nails or foods? *
Bronchitis, asthma, COPD or other chest conditions? *
Fainting attacks, Meniere’s vertigo, blackouts and/or epilepsy? *
Heart problems, heart attack, angina, blood pressure problems, stroke, rheumatic fever and/or arrythmias? *
Suffer from sleep apnoea and/ or excessive snoring? *
Diabetes? (or does anyone in your family) *
Bone or joint disease (e.g. arthritis, osteoporosis)? *
Bruising or persistent bleeding following injury, tooth extraction or surgery? *
Liver disease (e.g. jaundice/hepatitis) or kidney disease? *
Any infectious diseases (including HIV and hepatitis)? *
A condition that led to your blood being refused by Blood Transfusion Service? *
A diagnosis of a long-term medical condition or syndrome, physical or mental (e.g. Alzheimer’s, Parkinsons, MS, Autism, Huntington’s)? *
A bad reaction to general or local anaesthetic? *
Brain surgery / Brain injury? *
Heart surgery (e.g. oblations, artificial valve, Stent, Pacemaker)? *
How many units of alcohol do you drink per week? *
Do you smoke or chew any tobacco products, or have you in the past, including vapes and Snus? *
Please supply details for both past usage and current numbers per day. *
Please give further or any other details which your dentist might need to know about, such as self-prescribed medicines (eg. aspirin).
