Swinton Dental Centre
Medical History Form

Name:______________________________________________
Address:____________________________________________________
_________________________________________________________
Postcode:__________________________
Date Of Birth: ____________________________
Male/Female
Telephone Number:_______________________________________
Mobile Number:_______________________________________
GP Name & Address_________________________________________
__________________________________________________________
NEXT OF KIN:
Name:________________________
Relationship To Patient:____________________________
Phone Number:____________________________
ARE YOU:
Expecting A Baby:____________________________
Taking Any Medication:  Yes/No _______________________________
__________________________________________________________
Receiving Medical Treatment :__________________________________
Covid-19 Status
Have You Had Any Vaccinations :_______________________________
Name Of Vaccination:_______________________________________
How Many Vaccinations Received:_______________________________
Date Of Last Vaccination:_____________________________________
HAVE YOU:
Had Rheumatic Fever Or Chorea:________________________________
Had Liver, Kidney Disease Or Hepatitis:___________________________
Had Heart Problems, Angina, Blood Pressure Problems:_____________
Had Any Blood Test Out Of The Ordinary:_________________________
Adverse Reactions To Either Local or General Anaesthetic:___________
Had A Joint Replacement:______________________________________
Any Allergies:______________________________________
Please Turn Over...

DO YOU:
Suffer From Arthritis :______________________________________
Have A Pacemaker Or Had Any Form Of Heart Surgery: _____________
Have Bronchitis Or Asthma:____________________________________
Have Epilepsy, Fainting Attack, Giddiness Or Blackouts______________
Have Diabetes Or Does Anyone In Your Family: ____________________
Do You Smoke: ___________________________
 How Many A Day : _______________
Previous Smoker: __________________________ 
When Did You Stop: _______________
How Many Units Of Alcohol Do You Drink Per Week: _______________
(1 Glass Of Wine = 2.1 units / Pint Of Alcohol = 3 units )
Bruise Easily: ________________________________________
Have HEP B OR HIV: ______________________________
Completed By: : ________________________________________
Date: ________________________________________