Fosse Dental Care

Tel: 0116 2621015

Surgery hours

Monday - Friday 9am - 6pm

Closed for lunch 1pm - 2pm

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Title
Full Name:
Email:
Are you currently pregnant?		Yes No
Are you currently receiving treatment from a doctor/hospital/clinic?		Yes No
If yes please give details:
Are you currently taking any prescribed medication?		Yes No
If yes please give details:
Are you carrying a medical warning card?		Yes No
Do you suffer from any allergies to medication, substances or foods?		Yes No
If yes please give details:
Do you suffer with hayfever?		Yes No
Do you suffer with eczema?		Yes No
Do you suffer with bronchitis, asthma or chest conditions?		Yes No
If yes please give details:
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?		Yes No
If yes please give details:
Do you suffer from heart problems, angina, blood pressure problems or stroke?		Yes No
If yes please give details:
Are you diabetic or is anyone in your family?		Yes No
Do you suffer from arthritis?		Yes No
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery		Yes No
Do you suffer from any infectious diseases (including HIV or hepatitis)?		Yes No
Have you ever has rheumatic fever or chorea?		Yes No
Have you ever had liver disease (e.g jaundice or hepatitis) or kidney disease?		Yes No
Have you ever had any other serious illness?		Yes No
If yes please give details:
Have you ever had blood refused by the Blood Transfusion Service?		Yes No
Have you ever had a bad reaction to general or local anaesthetics?		Yes No
If yes please give details:
Have you ever had a joint replacement or any other Implant?		Yes No
Have you ever had any treatment that required you to be in hospital?		Yes No
If yes please give details:
Have you ever had heart surgery?		Yes No
Have you ever had brain surgery?		Yes No
Did you receive growth hormone treatment before the mid 1980’s?		Yes No
Do you have any close relatives with creutzfeldt jakob disease?		Yes No
Do you regularly drink more than 14 units of alcohol per week?		Yes No
Do you smoke or have you smoked in the past?		Yes No
Do you chew tobacco, pan, or use guthka or supari now or have you in the past?		Yes No
Is there any other information which your dentist may need to know such as self prescribed medications?

Tel: 0116 2621015

Medical History form

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