Confidential Patient Questions Medical History EnhanceSurname- Select -Dr.Mr.Mrs.Miss.Ms.Full NameMobile NumberAddressFull Address CityStatePost CodeDate Of BirthWork PhoneNHS Exempt Yes NoDetails of ExemptionNHS NumberEmailOccupationHome PhoneGP Surgery NamePhone (If known)Are you receiving any medical treatment? Yes NoDetailsHave you been hospitalized during the past two years? Yes NoDetailsHave you taken any medicines during the past two years? Yes NoDetailsAre you allergic to anything including medicines etc? Yes NoDetailsHave you had any prosthetic surgery? Yes NoDetailsIf woman, Are you pregnant? Yes NoHow many monthsDo you smoke? Yes NoIf yes how many cigarettes a day? Do you drink alcohol? Yes NoHow many units of alcohol do you drink per week?Have you ever had any of the following? If so, please tick as appropriate. Rheumatic Fever Epilepsy Cold Sores Heart Trouble Anaemia Mental Health Conditions High Blood Pressure Diabetes Drug Dependence Asthma Kidney Trouble Hepatitis Arthritis Gastric Problems Bronchitis or Chest Problems Specify type Hepatitis A Hepatitis B Hepatitis CName of Last DentistApproximate date of last dental visitDo you have Dental pain or a Dental problem at present? Yes NoDetailsHave you ever experienced excessive bleeding or bruising from dental treatment, cuts? Yes NoDo you become anxious or uncomfortable when you are having dental treatment? Yes NoReferred By Google Facebook Street Sign Another patient/friendNameI hereby consent to the dental surgeon to carry out dental treatment, identified, discussed and agreed. I agree to be liable for any charges that may arise following treatment (this includes any debt collection surcharges).Payments are taken at each visit.I have read and agree to the Terms and Conditions.Patient/Parent/GuardianDateThe data protection act and GDPR prevents any person or organisation from accessing or sharing personal information on an individual without their express permission. Should you wish for another individual to be able to make/amend/discuss your dental appointments/information on your behalf, please confirm below: Yes NoFull NameRelationshipPhone NumberDetails of person to contact in an emergencyRelationshipPhone NumberI authorise Enhance Dental Centre to contact me in the following methods regarding my personal dental information/appointments Home Phone Mobile Work Phone Email LetterPatient/Parent/GuardianDateSubmit
