Confidential Medical Questionnaire for Dental Patients

Section A. Personal Details

Section B. Medical Questions

Are you currently in good health?
- If you are currently under treatment by a Doctor please record the reasons below:

- If you are taking any medication or drugs (either prescribed or bought over-the–counter) or carry a drugs warning card please record below:

- If you suffer from any allergies please record below:

Do you suffer or have you ever suffered from any of the following conditions?
Rheumatic Fever
Any heart problems/heart murmer
High Blood Pressure
Chest Problems (asthma, bronchitis, TB etc.)
Diabetes
Epilepsy/ Fainting
Hepatitis/Jaundice
Have you been in hospital for operations or illness?
Do you have any problems stopping bleeding?
Are you pregnant?
Have you ever had any of the following?
A bad reaction to general or local anaesthetic?
A pacemaker fitted?
A blood-borne infection?
Sterioids within the last two years?

C. Lifestyle Questions

Do you smoke tobacco products?
If yes, please select all that apply.
Cigarettes
Cigars
A Pipe
Other (please state)
Do you drink alcohol?
If yes, how many units per week?
1 pint = 2 units, 1 measure of spirits = 1 unit, 1 glass of wine = 1 unit

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