Medical History Form - Torbay and Southern Devon Health and

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PATIENT ASSESSMENT & MEDICAL HISTORY QUESTIONS (April 2014)
Mrs Miss Ms Mr Mstr
Sex M / F
First name
Date of birth
Address
Doctor
Name
Surname
Address
POSTCODE
Contact number/s
National Insurance No:
Ethnicity Child’s school –
Do you want us to share your information with a specific person?
Name -
Yes / No
NHS number:
Relative / Friend / Carer
Contact information – Telephone number / email?
Do you have, or have you had:
Heart disease, surgery, murmur, rheumatic fever
Chest pains, angina, swollen ankles
Problems with blood pressure
Pacemaker, thrombosis, other
Bronchitis, pneumonia, pleurisy
Emphysema, chest surgery, cystic fibrosis
Breathlessness on exercise or at night
Other chest condition
Hepatitis B, C, HIV or had blood transfusion
Bleeding problems, abnormal bruising
Anaemia, sickle cell
Haemophilia, other bleeding disorder
Diabetes (sugar in urine)
Jaundice, liver disease
Kidney, urinary problems
Epilepsy, convulsions, fits
Indigestion, hiatus hernia
Do you faint easily?
Any inherited diseases within the family
Mental health problem, learning disability,
autism, Special needs or syndrome, etc.
Any other serious illness or condition
e.g. cancer, osteoporosis
Previous general anaesthetics for any operation,
including dental treatment
If “yes”, were there any problems
Family history of general anaesthetic problems
Weight stones/pounds or kilograms
Are you pregnant, or think you might be?
Are you breast feeding?
Do you drink alcohol?
Do you smoke? Chew tobacco?
Do you take recreational drugs?
Allergy to penicillin
Asthma, eczema, hay fever
Allergic to, or had any reactions to any medicines,
drugs, local anaesthetic, food, elastoplast, latex etc
Taking steroids or had any in the past year
Taking any medicines, drugs, pills, inhalers,
No
Yes
- give details please
Details please
Please list medication
suppositories or skin creams, contraceptive pill etc
Date ✘.............................. Signature ✘....................................... Relationship to patient ✘...................................
Checked Date ✘........................
Dentist’s Signature ✘................................... Dentist’s Name ✘...............................................................
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