Medical Histroy And Covid-19 Risk Assessment Form

Call Us on 01462 420825

COVID-19

You can either download this form and complete form.

It is editable using your computer, so just open it and click on the box you want to edit and type, save it, then upload here:

Please complete this within 24 hours of your appointment
- Upload Medical History Form*
Or you can just complete this online form
- Title
- First name*
- Last name*
- Sex*
- Preferred Name*
- DOB(dd/mm/yyyy)*
- Address*
- Post Code
- Home Phone*
- Mobile
- Occupation
- In the event of an emergency, please contact
- Name*
- Phone*
- Relationship to you*
- Doctor’s details
- Doctor’s Name
- Address*
- Post Code
- Are you currently:
- Receiving treament from a doctor, hospital or clinic?*
- - Yes
  - No
- Please give details.
- Taking any prescribed medicines *e.g. warfarin, bisphosphonates, or other tablets, ointments, injections or inhalers, including contraceptives and hormane replacement therapy?*
- - Yes
  - No
- Please give details.
- Carrying a medical warning card?*
- - Yes
  - No
- Please give details
- Pregnant or possibly pregnant?
- - Yes
  - No
- Please give details
- Have you ever had:
- Allergies to medicines (e.g. penicillin), substances (e.g. latex/rubber) or foods?*
- - Yes
  - No
- Please give details.
- Bronchitis, asthma or other chest conditions?*
- - Yes
  - No
- Please give details
- Fainting attacks, giddiness, blackouts, epilepsy?*
- - Yes
  - No
- Please give details
- Heart problems, angina, blood pressure problems or stroke?*
- - Yes
  - No
- Please give details
- Diabetes (or does anyone in your family)?*
- - Yes
  - No
- Please give details
- Bone or joint disease?*
- - Yes
  - No
- Please give details
- Bruising or persistent bleeding following injury, tooth extraction or surgery?*
- - Yes
  - No
- Please give details
- Liver disease (e.g. jaundice, hepatitis) or kidney disease?*
- - Yes
  - No
- Please give details
- Any other serious illness or infectious disease?*
- - Yes
  - No
- Please give details
- Blood refused by the Blood Transfusion Service or any other agency abroad?*
- - Yes
  - No
- Please give details
- A bad reaction to general or local anaesthetic?*
- - Yes
  - No
- Please give details
- Treatment that required you to be in hospital?*
- - Yes
  - No
- Please give details
- Heart surgery or a stent?*
- - Yes
  - No
- Please give details
- Any form of mental illness (e.g. depression, anxiety, stress, eating distorders)?*
- - Yes
  - No
- Please give details
- Alcohol
- How would you describe your consumption of alcohol? Non-drinker, modest, moderate, more than is probably good for me, heavy?*
- Smoking
- Do you smoke any tobacco products now (or did you in the past?*
- - Yes
  - No
  - In the past
- How many times per day?
- Do you chew tobacco, pan, use gutkha, supari, or betel now (or did you in the past)?*
- - Yes
  - No
  - In the past
- How many times per day?
- Would you like help or advice reducing or quitting alcohol or tobacco products?*
- - Yes
  - No
- How many times per day?
- Please give any other details which your dentist might need to know about such as self-prescribed medicines (e.g. Aspirin) or any disabilities or health concerns you may have.*
- Please rate your dental nervousness or anxiety 0-10 (0 not nervous at all, 10 too anxious to consider treatment)*
- Disclaimer
- Completed by:*
- - Self
  - Parent
  - Guardian
  - Other
- If Other - Please state
You can either download this form and complete form.

It is editable using your computer, so just open it and click on the box you want to edit and type, save it, then upload here:

Please complete this within 24 hours of your appointment
- Upload Covid-19 Risk Assessment Form*
Or you can just complete this online form
- Title*
- First name*
- Last name*
- Sex*
- Preferred Name*
- DOB(dd/mm/yyyy)*
- Address*
- Post Code
- Home Phone
- Mobile*
- Occupation
- Email*
- In the event of an emergency, please contact
- Name*
- Phone
- Relationship to you
- Doctor’s details
- Doctor’s Name*
- Post Code*
- Address
- All details are strictly confidential
- Have you travelled by public transport today?*
- - Yes
  - No
- Loss of taste and/or smell*
- - Yes
  - No
- Have you recently developed any of the following symptoms?*
- - Yes
  - No
- Headaches*
- - Yes
  - No
- Persistent cough*
- - Yes
  - No
- Itchy eyes*
- - Yes
  - No
- High temperature*
- - Yes
  - No
- Diarrhoea*
- - Yes
  - No
- Shortness of breath*
- - Yes
  - No
- If ‘YES’ to any of these questions please supply details and inform and member of staff
- Disclaimer
- Completed by:*
- - Self
  - Parent
  - Guardian
  - Other
- If Other - Please state