Forms New Patient QuestionnaireMedical History UpdateTooth Extraction: Request an AppointmentPeriodontal Treatment: Request an AppointmentDental Hygiene: Request an AppointmentTooth Extraction: Medical HistoryPeriodontal Questionnaire Patient Medical History Update Medical History Update Form Name* First NameLast Name Date of birth (type in or use calendar)* -Day -MonthYearDate Location HoveHaywards Heath 1. Do you have any problems with your heart, including high blood pressure or atrial fibrillation?* YesNo 2. Do you have any problems with your breathing?* YesNo 3. Are you epileptic or diabetic?* YesNo Please detail below 4. Have you ever been diagnosed with "weak" bones or osteoporosis?* YesNo 5. Do you take regular medication?* YesNo Please detail below 6. Are you allergic to any medication (including penicillin) or to latex?* YesNo If yes, please detail below 7. Do you have any other allergies?* YesNo If yes, please detail below 8. Do you have any problems with your stomach when taking medication?* YesNo 9. Have you ever had any problems with excessive bleeding?* YesNo 10. Are you pregnant or trying to conceive?* YesNo 11. Have you ever had any form of cancer?* YesNo 12. Have you ever had any major operations or serious illness?* YesNo 13. Do you currently smoke, or given up recently?* YesNo If yes, how many did you smoke per day? 14. Is there anything else about your medical history that you think we should know? YesNo If yes, please detail below Submit Should be Empty:
