Medical History & the Practice Information

Medical History Questionnaire  

Please fill in and answer the following questions. This must be completed 24 hours before your appointment.

Patient Name (required)

Contact Phone number

Home Postcode

Are you receiving any treatment from a doctor/specialist/hospital/clinic?

Are you taking any prescribed medication (Such as tablets, creams, inhalers, injections, contraceptives or HRT, if so please type them below?

Do you or anyone in your immediate family have diabetes?

Are you allergic to any medicines or materials, if so please type them below?

Do you have a Medical Warning Card, if so please bring it to your appointment

Do you have angina or high/low blood pressure?

Do you have bronchitis, asthma, or any other chest condition?

Do you bruise easily or bleed excessively?

Do you have fainting attacks, giddiness, blackouts, or epilepsy?

Do you smoke or use tobacco products (such as paan or gutkha)?

Have you ever used tobacco products in the past?

Do you drink alcohol?

Do you/the patient have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Have you ever had rheumatic fever?

Have you ever had a heart attack?

Have you ever had heart surgery or a pacemaker fitted?

Have you ever had a stroke?

Have you ever had jaundice, liver, kidney disease, or hepatitis?

Have you ever had a joint replacement or other implants?

Have you ever had a bad reaction to general or local anesthetic?

Have you taken steroids in the last two years?

Ladies Only, Are you pregnant?

Declaration: I confirm that to the best of my knowledge, the information I have provided on this form is accurate and complete.

Please type your name below to confirm.


The Practice Information

On the day of the appointment please arrive at your appointment time.

We recommend entering with your face mask on.

Please re-confirm that you/the patient is still symptom-free at your appointment before entering.

We recommend sanitising your/patient’s hands.

The dental practice is equipped with a ventilation system with no air recirculation ensuring fresh air at all times.

Please contact us a month before your recommended recall by SMS or email.

Thank you,

Kind regards, Reception Team

Willerby Dental Care, 81 Kingston Road, Willerby, HU10 6AH,, SMS 07817176134