place
36 Buchanan St, Balfron, Glasgow, G63 0TR
phone
01360 440777
email
cherrybankdentalbalfron@gmail.com
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Confidential Medical History Update
Step 1 of 3
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Patient Name
*
Date of Birth
*
DD
MM
YYYY
Pacemaker
*
Yes
No
Epilepsy
*
Yes
No
Diabetes
*
Yes
No
Heart Problems
*
Yes
No
Liver or Kidney Disease
*
Yes
No
Asthma
*
Yes
No
Allergy to any medicines (eg. Penicillin)
*
Yes
No
Heart Murmur
*
Yes
No
Joint Replacement
*
Yes
No
Chest Problems
*
Yes
No
Allergies (including Latex)
*
Yes
No
High Blood Pressure
*
Yes
No
Hepatitis
*
Yes
No
Bleeding Disorder
*
Yes
No
Heart Surgery
*
Yes
No
Blackouts/ Fainting Attacks/ Giddiness
*
Yes
No
Have you ever been on Alendronic Acid (Fosamax) or similar medications for Paget’s Disease, Osteoporosis or cancer treatment?
*
Yes
No
Have had or are a carrier of a blood borne virus? Eg HIV/ Hepatitis
*
Yes
No
Any pills/medication? (please list)
Bad reaction to a general anaesthetic?
*
Yes
No
Bad reaction to a local anaesthetic?
*
Yes
No
Have you been in hospital for any operations /serious conditions in the last 5 years?
*
Yes
No
Taken steroids in the last 2 years?
*
Yes
No
Do you carry a warning card?
*
Yes
No
If female, are you or do you think you may be pregnant?
Yes
No
If true to any of the questions above please give further information
Are you seeing a doctor at present?
*
Yes
No
Name of your doctor
Address of your doctor
Patient (or parent/guardian) digital signature
*
I Agree
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