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Medical History
Update your medical history below using our secure form.
Update Your Medical History
Medical
Please fill out our secure form below with all your details.
Personal Details
Title
Select
Ms
Miss
Mrs
Mr
Dr
Forename
Surname
Date of Birth
Mobile Number
Email Address
Sex
Occupation
GP Details
Why did you choose Calderwood Dental?
Where/When was your last dental treatment?
Do you have an exemption from dental charges?
If so which one?
Add To Email List
Select
Yes
No
Your Address
Address 1
Address 2
Address 3
City
Postcode
Medical Questions
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
Select
Yes
No
Are you taking any medicines from your doctor?
(tablets, ointments, injections or inhalers)
Please list ALL medications
Select
Yes
No
Are you allergic to any medicines, food or materials?
Select
Yes
No
Do you Smoke?
If yes, how many cigarettes per week?
Select
Yes
No
Do You Consume Alcohol?
If Yes, What is your average weekly alcohol intake?
Select
Yes
No
Are you pregnant or likely to be pregnant?
Select
Yes
No
Are you concerned about any other aspects of your health your dentist should know about?
Select
Yes
No
Have You Any Problems With
Heart / Angina?
Select
Yes
No
Blood Pressure?
Select
Yes
No
Bronchitis, asthma or any other chest condition?
Select
Yes
No
Liver or kidneys?
Select
Yes
No
Fainting attacks?
Select
Yes
No
Bleeding after surgery or tooth extraction?
Select
Yes
No
Headaches / migraines, neck or back pain?
Select
Yes
No
Diabetes?
Select
Yes
No
Epilepsy?
Select
Yes
No
Form Details Completed By
Please Select Box Where Applicable:
Form Completed By Self?
Form Completed By Parent?
Form Completed By Guardian?
Thank you!
All your latest medical history details have been received.
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