Patient’s Name Date of Birth SECTION 13 PATIENT MEDICATIONS Please list all current medications SECTION 14 CONFIDENTIAL MEDICAL HISTORY FORM PLEASE ANSWER ALL QUESTIONS YES NO DETAILS PLEASE STATE – Has the patient ever been admitted to hospital? Has the patient had any operations? ☐ ☐ Is this patient attending or receiving treatment from a ☐ ☐ doctor, hospital, clinic or specialist? Has the patient ever had a general anaesthetic? ☐ ☐ If YES, where, when and what for? Has the patient had a bad reaction to a general or local ☐ ☐ anaesthetic? Is the patient taking any medicines (tablets, creams, ☐ ☐ ointments, injections, including Warfarin, aspirin, – contraceptives and HRT) or alternative remedies? Please specify Please bring repeat prescription/MARS sheet (if applicable) Is the patient taking or has taken steroids in the last two ☐ ☐ years? Is the patient using or has ever used recreational drugs? ☐ ☐ ☐ ☐ Is patient allergic to any medicines or food substances? Does the patient suffer from Parkinson’s disease, ☐ ☐ neurone disease, or other neurological condition? Has the patient ever been told they have a heart murmur, ☐ ☐ heart disease, high blood pressure, angina, heart attack, stroke or heart surgery? PLEASE ANSWER ALL QUESTIONS YES NO DETAILS PLEASE STATE – Does the patient have a pacemaker, VNS implant, stent, ☐ ☐ artificial valve, shunt, or other form of implant? Has the patient ever had jaundice, liver, kidney disease or ☐ ☐ hepatitis? Does the patient suffer from allergies e.g hay fever or ☐ ☐ eczema? Does the patient suffer from bronchitis, asthma or other ☐ ☐ chest conditions/snoring/sleep apnoea? Does the patient have fainting attacks, giddiness, blackouts ☐ ☐ or epilepsy?
Patient’s Name Date of Birth SECTION 13 PATIENT MEDICATIONS Please list all current medications SECTION 14 CONFIDENTIAL MEDICAL HISTORY FORM PLEASE ANSWER ALL QUESTIONS YES NO DETAILS – PLEASE STATE Has the patient ever been admitted to hospital? Has the patient had any operations? ☐ ☐ Is this patient attending or receiving treatment from a doctor, hospital, clinic or specialist? ☐ ☐ Has the patient ever had a general anaesthetic? If YES, where, when and what for? ☐ ☐ Has the patient had a bad reaction to a general or local anaesthetic? ☐ ☐ Is the patient taking any medicines (tablets, creams, ointments, injections, – including Warfarin, aspirin, contraceptives and HRT) or alternative remedies? Please specify Please bring repeat prescription/MARS sheet (if applicable) ☐ ☐ Is the patient taking or has taken steroids in the last two years? ☐ ☐ Is the patient using or has ever used recreational drugs? ☐ ☐ Is patient allergic to any medicines or food substances? ☐ ☐ Does the patient suffer from Parkinson’s disease, neurone disease, or other neurological condition? ☐ ☐ Has the patient ever been told they have a heart murmur, heart disease, high blood pressure, angina, heart attack, stroke or heart surgery? ☐ ☐ PLEASE ANSWER ALL QUESTIONS YES NO DETAILS – PLEASE STATE Does the patient have a pacemaker, VNS implant, stent, artificial valve, shunt, or other form of implant? ☐ ☐ Has the patient ever had jaundice, liver, kidney disease or hepatitis? ☐ ☐ Does the patient suffer from allergies e.g hay fever or eczema? ☐ ☐ Does the patient suffer from bronchitis, asthma or other chest conditions/snoring/sleep apnoea? ☐ ☐ Does the patient have fainting attacks, giddiness, blackouts or epilepsy? ☐ ☐
special_care_dental_service_referral_form_v7.docx