Please answer all questions honestly. All information is strictly confidential.
Have you ever had heart trouble or high blood pressure?
Have you been a patient in hospital in the past 2 years?
Are you under current medical treatment?
Are you taking any regular drugs or medicine?
Have you had any other serious illness e.g. deep ray therapy or cancer?
Have you ever had rheumatic fever, diabetes, hyperthyroidism, asthma, glaucoma, nervous disorder, anaemia, tuberculosis, HIV, hepatitis, epilepsy, psychiatric treatment or strokes?
Have you any known allergies to drugs (especially penicillin), medicines or local anaesthetic?
Women — if pregnant, state how many months?
Have you ever experienced prolonged bleeding?
Are you a smoker?
Declaration & Signature
I declare that the information provided is accurate and complete to the best of my knowledge. I consent to the dental treatment proposed for me and understand that my health details will be kept strictly confidential.