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River Mole Dental
Tel: 01932 866252
rivermoledental@gmail.com
Medical History Form
Please fill out the form before your appointment
Full Name
Date of birth
Email
Phone
Address
Are you an expectant mother?
*
No
Yes
Are you exempt from dental charges
*
No
Yes
Had rheumatic fever, cholera, jaundice, hepatitis, kidney disease?
*
No
Yes
Had any heart problems, a heart murmur, angina, high blood pressure, heart attack or any heartsurgery such as valve replacement or pacemaker?
*
No
Yes
Have diabetes or does anyone in you family?
*
No
Yes
Bruise easily following a tooth extraction, surgery or injury or do you or your family have bleeding disorders?
*
No
Yes
Allergic to any medicines, foods or materials?
*
No
Yes
HIV Positive or do you or any close relatives suffer from CJD?
*
No
Yes
Suffer from Epilepsy, fainting, giddiness or blackouts or do you have Asthma?
*
No
Yes
Carry a warning card?
*
No
Yes
Do you smoke?
*
No
Yes
Taking any medication?
*
No
Yes
Are you taking or have you taken steriods in the last two years?
*
No
Yes
Have you had a joint replacement?
*
No
Yes
If you answer yes above please provide details and list all medications. If you have any other medical condition please provide details below. Please also provide your GP details.
Submit
Thanks for submitting!
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