Medical History Form 1Patient Registration 2Medical History Form HiddenDate - completed form MM slash DD slash YYYY Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact DetailsAddress* Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mobile Number*Home Phone NumberEmail* Enter Email Confirm Email Newsletter Yes, Sign me up to receive health tips, special offers and much more. HiddenOccupationPlease selectAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherOccupation other Date of last dental visit 3 months ago 6 months ago 12 months or more When did you last have a dental visitLikes and dislikes at dental visitsWhere did you learn about the practice?* Leaflet/Advert Passing by Google Search Facebook Instagram Recommended by friend/family member ? Cinema advert Radio advert Google reviews Their name/relationship to you Would you like us to see any of your friends or family also: Yes No Name(s):NamePhone Number I wish to register as a patient with a dentist at Parrock Dental & Implant Centres I understand and agree the following That the agreement by which I will be given dental treatment is an arrangement between the dentist and myself. That, under my treatment plan, my treatment will have to be paid for in total by the last visit. That, under my treatment plan; I may be required to pay in advance for certain items of treatment. That, under my treatment plan, I may be charged a fee of £10 for each 10 minutes of an appointment missed or cancelled without 48 hours prior notice. Signature*Date DD slash MM slash YYYY Doctors surgeryDoctors Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Are youReceiving treatment from a doctor, hospital, clinic or a specialist? Yes No If Yes, give informationAre you currently taking any medicines or tablets (creams, ointments, injections)? Yes No If Yes, give informationAre you allergic to any medication such as antibiotics?* Yes No Please list all medications you are allergic to* Are you taking or have taken steroids in the last two years? Yes No If Yes, give informationHave YouHad rheumatic fever or chorea? Yes No If Yes, give informationHad jaundice, liver disease or hepatitis? Yes No If Yes, give informationEver been told you have a heart murmur or heart problems, angina or heart attack? Yes No If Yes, give informationHigh or Low Blood Pressure? If yes, do you know what it is? Date last taken? Yes No If Yes, give informationHad any blood tests? If so what for? Yes No If Yes, give informationEver had your blood refused by the blood transfusion service? Yes No If Yes, give informationEver had a reaction to a general or local anesthetic? Yes No If Yes, give informationHad a joint replacement? Yes No If Yes, give informationBeen hospitalized? If so what for? Yes No If Yes, give informationDo youHave arthritis or joint problems / osteoporosis? Yes No If Yes, give informationHave a pacemaker, or have you had any heart surgery? Yes No If Yes, give informationSuffer from hayfever, eczema or any other allergy? Yes No If Yes, give informationSuffer from bronchitis, asthma or any chest conditions? Yes No If Yes, give informationHave fainting attacks, blackouts or epilepsy? Yes No If Yes, give informationHave diabetes or does any one in your family? Yes No If Yes, give informationHave any bleeding disorders? Yes No If Yes, give informationCarry a warning card? Yes No If Yes, give informationEver get cold sores? Yes No If Yes, give informationEver Smoke?* Yes No If Yes: Current Ex- Smoker (smoking is a high risk factor for causing poor appearance and failure/ loss of teeth, gums and dental implants) How many a day?How many years?Drink Alcohol? Yes No How many units a week? (1 unit = ½ pint beer, 1 glass wine, 1 measure of spirit)Take any of the following medicines below?Antibiotics Yes No Diuretics Yes No Antidepressants Yes No Insulin Yes No Anticoagulants Yes No INRSteroids Yes No Antihistamines Yes No Hormones Yes No Blood pressure Tablets Yes No Tranquillizers Yes No Aspirin Yes No Bisphosphonates Yes No eg. FosomaxPlease give more details about medicines/Further information?Females OnlyAre you pregnant? Yes No Please list all medication taken including dose and how many taken per dayDo you take oral contraceptives Yes No Have you had a hysterectomy Yes No Are you past the menopause Yes No Any other aspect of your health your dentist should know about?I consent to my General Medical Practitioner to be contacted for further medical information if and when required I have disclosed all relevant medical conditions Signature*Date DD slash MM slash YYYY Completed by:* Self Parent Guardian Signature*
