New Patient Medical History Form

New Patient Medical History Form
Patient’s details
Patients Address
Emergency contact
Referring Dentist or Referral Source
Medical History
Have you ever had had any of the following? Please tick those that apply
Have you ever taken any of the following medications? Please tick those that apply.
Please indicate (tick) if you are allergic to any of the following.
List any other drugs or medications you cannot take or are allergic to
List any drugs or medications you routinely take
(Women) Are You
Pregnant Now?
Nursing?
Taking Birth Control Pills?
Have you been hospitalised in the last two years?
Does dental treatment make you nervous?
Have you ever had the following for dental treatment?
Gas (Nitrous oxide/laughing gas)
Intravenous sedation
General Anesthesia
CONSENT FOR SERVICES