Medical History Form - Lighthouse Dental Practice

Phone

Title *

Surname *

Forename(s) *

Date Of Birth

Mobile Number

I give permission to be contacted on the telephone number

Address

Occupation:

Do you require the stairlift ?

(requirement under 120kgs)

Where did you hear about us?

GP Details *

Are you currently receiving treatment from your GP or hospital? *

Yes

If yes please give details

Do you experience any heart problems or angina? *

Yes

If yes please give details

Are you taking any medication/tablets/ please list? *

Yes

If yes please give details

Are you recovering from a GA/Op/hospital? *

Yes

If yes please give details

Are you Diabetic? *

Yes

If yes please give details

HPV- Human Papillomavirus? *

Yes

If yes please give details

Do you suffer from any serious illness or condition? *

Yes

If yes please give details

Do you have any known allergies? *

Yes

If yes please give details

Do you suffer from chronic Bronchitis, Asthma or any other respiratory disease? *

Yes

If yes please give details

Had epilepsy, blackouts, giddiness or fainting? *

Yes

If yes please give details

Had hepatitis, Jaundice, Liver or Kidney disease? *

Yes

If yes please give details

Had excessive bleeding and/or bleeding disorders? *

Yes

If yes please give details

Do you have a pacemaker fitted? *

Yes

If yes please give details

Suffer from Arthritis? *

Yes

If yes please give details

Ever undergone a joint replacement operation? *

Yes

If yes please give details

Received steroid therapy in the past two years? *

Yes

If yes please give details

Do you suffer from herpes or cold sores? *

Yes

If yes please give details

Are you HIV positive? *

Yes

If yes please give details

Family history of mouth cancer? *

Yes

If yes please give details

Had an allergic reaction to either local or general anaesthetic? *

Yes

If yes please give details

How many units of alcohol per week? *

Yes

If yes please give details

How many cigarettes per week? *

Yes

If yes please give details

Do you use chewing tabacco? *

Yes

If yes please give details

Have you ever had SEPSIS? *

Yes

If yes please give details

Female patients

Are you a mother of a child under 12 months?

Yes

Are you expecting a baby?

Yes

If yes please specify the due date:

Exemption from Dental charges

Are you under 18 years? *

Yes

Are you 18 years and in full time education? *

Yes

(please give details of the school/college)

Are you named on a valid HC2 Exemption certificate? *

Yes

Do you receive any of the following: PROOF WILL BE ASKED FOR/REQUIRED? *

Pension Credit

Income Support/ESA

Tax Credit

Universal Credit

N/A

COVID-19 ASSESSMENT - Do you have any of the following symptoms of Covid 19:

New continuous cough? *

Yes

High Temperature above 37.8? *

Yes

Change in taste or smell? *

Yes

Sore Throat? *

Yes

Have you been diagnosed or had Covid-19? *

Yes

(please give details and state proof of test date)

Are you vulnerable or shielding? *

Yes

Would you consider yourself high risk? *

Yes

Are you currently living in a care home? *

Yes

Is your background ethnic? *

Yes

Were you born outside of the UK or Ireland? *

Yes

NHS Patients Under NHS regulations, we are unable to charge NHS patients who fail to attend for their initial appointments or who cancel at short notice (less than 24 hours notice is insufficient notice). A patient who fails to attend their new patient appointments or cancels at short notice, may not be offered any further appointments at this practice, but you may seek another NHS practice elsewhere. Please sign below to acknowledge this statement.

Consent

I agree to the photographs being taken by Lighthouse Dental Practice Ltd and consent to their use for the purposes described below, and in accordance with current data protection legislation. When used for any purpose not directly related to my care, the photographs will be made anonymous by obliterating the face so that I cannot be personally identified when they are used in lectures or publications which will include: - Clinical purposes relating to my treatment and kept with my confidential dental records - For teaching purposes with other dental professionals - For demonstrating clinical techniques - For Social Media

https://www.lighthousedental.uk/gdpr-policy/ *

Declaration

I hereby apply to become a patient of Lighthouse Dental Practice. I undertake to settle all fees when due. I understand that interest may be paid on overdue accounts and that seriously overdue accounts may incur extra fees.

Signed By:

Dated: