Medical History Form

Please complete the medical history form below and click the submit medical history button.

1. Patient Details

Title:
Forename:
Surname:
Gender:
Address:
Postcode:
Date of Birth:
Home Phone:
Mobile Phone:
Occupation:
Email Address:
Approx. Date of Last Visit:

2. How Did you Hear About us?

How did you hear about us?





If we were recommended to you, please state by whom?

3. Medical History

Are you currently receiving any medical treatment from a doctor, hospital or clinic?
Are you currently taking any prescribed medicines, inhalers, injections or tablets?
Do you carry a medical warning card?
Have you suffered any allergies to medicines, substances or foods? i.e. Penicillin or Latex
Are you, or have you been, under the care of a doctor during the past two years?
Have you ever had any of the following? If so, please tick as appropriate












Have you had any prosthetic surgery? (E.g. Heart Valve or Hip Replacement)
Are you pregnant or possibly pregnant?
Have you ever had your blood refused by the Blood Transfusion Service?
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
How many units of alcohol do you drink a week?
(One unit is a half a pint of lager, a single measure of spirits or a small glass of wine/aperitif)
Do you smoke any tobacco products now, or in the past?
Do you chew tobacco, pan, use gutkha or supari now or in the past?

4. Additional Details

Please give any other details which your dentist might need to know about, such as self-prescribed drugs (e.g. aspirin) or any disabilities you may have:
Medical Doctor's Name:
Doctor's Telephone Number:
Practice Address:
Doctor's Postcode:

We want to ensure all your dental needs are met. Please indicate if you have any concerns with any of the following:

I am self-conscious about my teeth when I smile:
My teeth are not as bright and white as I would like them to be:
I am unhappy about the colour of my crowns or fillings:
Some of my teeth are chipped or misshapen:
I have gaps that show:
I would like my teeth to look straighter:
I am concerned about my gums receding:
I am concerned about bad breath:
My gums bleed when I brush my teeth:
My teeth are sensitive:
My dentures feel uncomfortable or loose:
I sometimes find I grind my teeth/clench my jaw:
I would like to enhance my lips:
I would like to reduce my lines and wrinkles:
How important is keeping your teeth? Please choose 1 being the lowest and 10 the highest
Where would you rate your current dental health: Please choose 1 being the lowest and 10 the highest

5. Sign Off

Completed by:
From time to time we'd like to send you details of our latest news, special offers and exclusive events from Castelau Dentists via email, post or SMS. We'll always treat your personal details with utmost care and we will never sell this information to others.
Please tick to certify that you have read and understood all the above information and that all of your answers are accurate and up-to-date. Any incorrect information can be dangerous to your health and you must inform us of any changes.
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Site last updated 12.07.2020