Medical Health Form | Valley Dental

Patient Information

Title

First Name*

Surname*

Email*

Date of Birth

Address *

Postcode

Home telephone number

Work telephone number

Mobile telephone number

New Patients - How did you hear about Valley Dental? e.g. Social media, personal recomendation, event

Preferred Channels of Communication

Please can you tick the relevant boxes to confirm your preferred channels of communication and that you consent to us using these to contact you. (Please note that e mails sent and received from unsecured e mail accounts may be accessible by third parties.)

Home Telephone
Mobile Telephone

Work Telephone
Email

We will only use the above information in order to remain in communication with you, remind you about appointment times, when dental check-ups and hygienist visits are due and for invoicing and payment purposes. We will not share any personal information with third parties without your prior consent and this will only be in relation to specific medical/dental healthcare pathways. We will never share your personal information for the purposes of advertising or marketing. Our data protection policies are available to view here. Please tick the consent box below if you consent to our use of your personal data as outlined above:

Consent Box

Details of General Medical Practitioner

GP Name

GP Telephone Number

GP Address

Emergency Contact details

Emergency Contact Name

Emergency Contact Telephone Number

Relationship to patient

Coronavirus Screening

Have you been diagnosed with the coronavirus?

YES NO

Have you been in contact with someone who has a confirmed case of coronavirus?

YES NO

Are you or your household self-isolating?

YES NO

Do you or have you had a temperature of 37.8 degrees C or above in the last 14 days?

YES NO

Do you or have you had a dry, persistent cough in the last 14 days?

YES NO

Have you noticed a loss of smell and/or taste in the last 14 days?

YES NO

Are you in the shielded patient group?

YES NO

If YES please give details

CONFIDENTIAL MEDICAL HISTORY FORM

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist at present?

YES NO

If YES please give treatment details

Are you currently taking any prescribed medicines? (e.g. tablets, ointments or inhalers, including contraceptives and hormone replacement therapy) - Please name the tablets etc

YES NO

If YES please give details.

Are you carrying a medical warning card?

YES NO

If YES please give details

Are you pregnant?

YES NO

If so, when is your due date?

Do you suffer from any allergies to medicines (e.g. penicillin, chlorhexadine), substances (e.g. latex or rubber) or foods?

YES NO

If YES please give allergy details

Do you suffer from Hay fever or eczema?

YES NO

If YES please give allergy details

Do you suffer from bronchitis, asthma, difficulty breathing or any other chest condition?

YES NO

If YES please give details. Do you use an inhaler(s)? (please specify)

Have you had or do you suffer from fainting attacks, giddiness, blackouts or epilepsy?

YES NO

If YES when was your last seizure?

Do you suffer from heart problems, angina, blood pressure problems or stroke?

YES NO

If YES please give heart disease details

Are you diabetic (or is anyone in your family)?

YES NO

If YES please give details. Do you take any medication to manage it (please give details) e.g Insulin, Metformin How well controlled is your diabetes?

Do you suffer from arthritis?

YES NO

If YES please give details

Have you ever had a joint replacement or any other implant?

YES NO

If YES please give reaction details

Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?

YES NO

If YES please give details. Are you taking any medication that might affect your clotting? e.g Warfarin, Apixoban, Clopidogrel, Aspirin

Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?

YES NO

If YES please give liver/kidney disease details

Do you suffer from any infectious diseases (including HIV and hepatitis)?

YES NO

If YES please give details

Have you ever had blood refused by the Blood Transfusion Service?

YES NO

If YES please give details

Have you ever had a bad reaction to general or local anaesthetic?

YES NO

If YES please give reaction details

Have you ever had treatment that required you to stay in hospital?

YES NO

If YES please give details

Have you ever had heart surgery?

YES NO

If YES please give details

Do you regularly drink more than 21 units of alcohol per week?

YES NO

If yes, approximately how many units per week?

Do you smoke any tobacco products now (or did you in the past)?

YES NO

If yes, How long have you smoked for? How much do you smoke per day? What do you smoke e.g Cigarettes, Cigars, Vape?

Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?

YES NO

If yes, How long have you done this for? How much do you use per day?

Have you ever had any other serious illness?

YES NO

If YES please give details.

Do you have any close relatives (parent, sibling, child, grandparent or grandchild) with Creutzfeldt jakob disease?

YES NO

If YES please give details

Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin)?

YES NO

If YES please give details

Are you concerned about your skin complexion?

YES NO

If YES please give details.

Are you concerned about fine lines and wrinkles?

YES NO

If YES please give details.

Are you concerned about loss of volume?

YES NO

If YES please give details.

Dental Treatment Consent During COVID 19

Thank you for your continued trust in our practice. As with any transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as ‘Coronavirus’ at any time, or in any place. Be assured that we will continue to follow all recommended government scientific guidance and use thorough personal protective equipment (PPE) and disinfectant protocols to limit transmission of all diseases.

Despite our careful attention to strengthen disinfection and the use of personal barriers, there’s is still a chance you could be exposed to an illness at the surgery, just as you might be whilst shopping. Nationwide social distancing has reduced the transmission of the coronavirus. Although we have taken measures to enable social distancing in our practice, due to the nature of the procedure, it is not possible to maintain social distancing between the patient, dental health care team members and sometimes other patients, at all times.

Although exposure is unlikely do you accept the risk of consent to treatment? *

YES NO

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