Medical History Form 1 Patient Registration 2 Medical History Form Date - completed form Date Format: MM slash DD slash YYYY Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact 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 IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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. OccupationPlease 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 otherDate of last dental visit3 months ago6 months ago12 months or moreWhen did you last have a dental visitLikes and dislikes at dental visitsWhere did you learn about the practice?*Leaflet/AdvertPassing byGoogle SearchFacebookInstagramRecommended by friend/family member ?Cinema advertRadio advertGoogle reviewsTheir name/relationship to youWould you like us to see any of your friends or family also:YesNoName(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 Date Format: 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 IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Are youReceiving treatment from a doctor, hospital, clinic or a specialist?YesNoIf Yes, give informationAre you currently taking any medicines or tablets (creams, ointments, injections)?YesNoIf Yes, give informationAre you allergic to any medication such as antibiotics?*YesNoPlease list all medications you are allergic to* Are you taking or have taken steroids in the last two years?YesNoIf Yes, give informationHave YouHad rheumatic fever or chorea?YesNoIf Yes, give informationHad jaundice, liver disease or hepatitis?YesNoIf Yes, give informationEver been told you have a heart murmur or heart problems, angina or heart attack?YesNoIf Yes, give informationHigh or Low Blood Pressure? If yes, do you know what it is? Date last taken?YesNoIf Yes, give informationHad any blood tests? If so what for?YesNoIf Yes, give informationEver had your blood refused by the blood transfusion service?YesNoIf Yes, give informationEver had a reaction to a general or local anesthetic?YesNoIf Yes, give informationHad a joint replacement?YesNoIf Yes, give informationBeen hospitalized? If so what for?YesNoIf Yes, give informationDo youHave arthritis or joint problems / osteoporosis?YesNoIf Yes, give informationHave a pacemaker, or have you had any heart surgery?YesNoIf Yes, give informationSuffer from hayfever, eczema or any other allergy?YesNoIf Yes, give informationSuffer from bronchitis, asthma or any chest conditions?YesNoIf Yes, give informationHave fainting attacks, blackouts or epilepsy?YesNoIf Yes, give informationHave diabetes or does any one in your family?YesNoIf Yes, give informationHave any bleeding disorders?YesNoIf Yes, give informationCarry a warning card?YesNoIf Yes, give informationEver get cold sores?YesNoIf Yes, give informationEver Smoke?*YesNoIf Yes:CurrentEx- 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?YesNoHow many units a week? (1 unit = ½ pint beer, 1 glass wine, 1 measure of spirit)Take any of the following medicines below?AntibioticsYesNoDiureticsYesNoAntidepressantsYesNoInsulinYesNoAnticoagulantsYesNoINRSteroidsYesNoAntihistaminesYesNoHormonesYesNoBlood pressure TabletsYesNoTranquillizersYesNoAspirinYesNoBisphosphonatesYesNoeg. FosomaxPlease give more details about medicines/Further information?Females OnlyAre you pregnant?YesNoPlease list all medication taken including dose and how many taken per dayDo you take oral contraceptivesYesNoHave you had a hysterectomyYesNoAre you past the menopauseYesNoAny 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 Date Format: DD slash MM slash YYYY Completed by:*SelfParentGuardianSignature*