Medical History Form Please provide us with the following information about your child to allow us to treat them safely. Please leave any areas you are unsure about blank and the oral healthcare team can discuss these with you. All information will be kept confidential by the people caring for your child. Please complete the form in BLOCK CAPITALS.
We ask you for information about your general health to help us treat you safely. Please complete your contact details below and answer all the health questions and then sign the back of the form. All information will be kept strictly confidential by our service.
CONFIDENTIAL MEDICAL HISTORY FORM To obtain best and safest treatment, your dentist needs toknow if any problems which may affect your treatment. ... 2 Have a pacemaker, or have you had any form of heart surgery? 3 Suffer from hay fever, eczema or any other allergy? 4 Suffer from bronchitis, asthma or any other chest condition? ...
Please check that the health information on this form is still correct. Please note any changes to your smoking, alcohol or medicine intake and list them in the notes field provided.
67 Medical History Forms [Word, PDF] - Printable Templates
Apr 10, 2017 · A medical history form is a means to provide the doctor your health history. Download free medical history form samples and templates.
It is important for your dentist to have your medical history and understand your health needs before any examination or treatment is carried out. If you are a new patient to the practice, please complete the following form for your first assessment.
Medical History Questionnaire Please complete this form, and then ENSURE that you bring it with you when you come to your Health Centre registration session. Surname (family name) .....
Medical History Form In order to provide you with the most appropriate and safest treatment, your den-tist needs to know about any previous or current medical conditions since many of them can affect your dental treatment. Completion of this questionnaire will help us to help you and together we will update your records at each new course
Please use this form to tell us about your medical history, and the medical history for anyone else you want to add to your cover (a dependant). We need this information to confirm your cover, process your claims and pay for any treatment you need that’s covered by your policy.
Have there been any changes in your health, medicines, injections or tablets since your last course or treatment?