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Search for:
Home
Services
General Dentistry
Prevention
Emergency Care
Hygiene Appointments
Cosmetic Dentistry
Teeth whitening
Porcelain veneer
Invisible braces
Restorative Dentistry
Invisalign dentistry
About
Who we are
Practice overview
Dental FAQs
Useful Links
Newsletter
NHS Information
Fees & Charges
Gallery
Contact
Search for:
114 Ellesmere Rd,
Shrewsbury SY1 2QT, UK
01743 243026
Call us today!
Opening Hours
Mon - Fri: 8:30 - 17:00
Book Appointment
greenfieldsdental@gmail.com
PATIENT MEDICAL HISTORY FORM
Salutation:
Mr
Master
Mrs
Miss
Ms
Dr
Other
Other Salutation:
Firstname:
Surname:
Date of Birth:
Sex:
Male
Female
Ethnicity(Optional):
Address:
Postcode:
NHS Number:
Telephone (Home):
Telephone (Work):
Mobile:
Email Address:
GP Surgery/Name:
How long since last full course of dental treatment?
Completed By:
Self
Parent
Guardian
The practice follows agreed procedures to keep your information secure and private
1. ARE YOU TAKING ANY PRESCRIBED MEDICINES (EG TABLETS, OINTMENTS OR INHALERS INCLUDING CONTRACEPTIVES AND HRT THERAPY)?
Yes
No
Details:
2. ARE YOU RECEIVING TREATMENT FROM A DOCTOR, CLINIC OR HOSPITAL?
Yes
No
Details:
3. ALLERGIC TO PENICILLIN?
Yes
No
Details:
4. ALLERGIES TO MEDICINES, FOODS OR MATERIALS?
Yes
No
Details:
5. WARFARIN OR OTHER ANTICOAGULANT (BLOOD THINNER)?
Yes
No
Details:
6. BRUISING OR PERSISTENT BLEEDING FOLLOWING INJURY, TOOTH EXTRACTION OR SURGERY?
Yes
No
Details:
7. HIGH BLOOD PRESSURE?
Yes
No
Details:
8. HEART PROBLEMS, ANGINA OR STROKE?
Yes
No
Details:
9. PACEMAKER?
Yes
No
Details:
10. HEART SURGERY?
Yes
No
Details:
11. BRAIN SURGERY?
Yes
No
Details:
12. EPILEPSY?
Yes
No
Details:
13. FAINTING ATTACKS, GIDDINESS OR BLACKOUTS?
Yes
No
Details:
14. LIVER DISEASE (JAUNDICE, HEPATITIS)?
Yes
No
Details:
15. KIDNEY DISEASE?
Yes
No
Details:
16. ASTHMA BRONCHITIS OR OTHER CHEST CONDITION?
Yes
No
Details:
17. DIABETIC?
Yes
No
Details:
18. HAVE YOU HAD A BAD REACTION TO LOCAL OR GENERAL ANAESTHETICS?
Yes
No
Details:
19. BONE OR JOINT DISEASE?
Yes
No
Details:
20. GROWTH HORMONE TREATMENT BEFORE THE MID 1980'S?
Yes
No
Details:
21. MEDICAL WARNING CARD?
Yes
No
Details:
22. DO YOU CONSUME MORE THAN 14 UNITS OF ALCOHOL WEEKLY?
Yes
No
Details:
23. DO YOU SMOKE ANY TOBACCO PRODUCTS (OR DID YOU IN THE PAST)?
Yes
No
Details:
24. DO YOU CHEW TOBACCO. PAN, USE GUTKHA OR SUPARI (OR DID YOU IN THE PAST)?
Yes
No
Details:
25. IS THERE ANY OTHER INFORMATION WHICH YOUR DENTIST MIGHT NEED TO KNOW ABOUT?
Yes
No
Details:
26. ARE YOU PREGNENT?
Yes
No
Details:
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For more information, please see our Privacy Notice displayed in the waiting room. I agree to conform to and abide by Greenfields Policies whilst a patient at Greenfields Dental Practice. (These policies are displayed in the Reception and Waiting Area)
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To support the preparations for Coronavirus (COVID-19), we have made changes to the services we provide
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