ARCOT DENTAL PRACTICE
        41 Silver Street, Lyme Regis, Dorset, DT7 3HR
                                   01297 442846
                                             arcotdental@gmail.com
                                                       www.arcotdental.com
                                                       Dr Sravan Arcot BDS
MEDICAL HISTORY
                       In confidence

Title( Mr./Mrs./Miss./Master./Dr.)  ……….. Surname……………………………..

Forename ……………………………………             Date Of Birth ………………………..

Address ………………………………………             Post Code…………………………...
               
 …………………………………………………            Telephone …...………………………

………………………………………………….            E-mail…..……………………………..

Mobile ………………………………………….            NI Number ……………………………. 
                   
Doctor ………………………………………….           Occupation…………………………….    

1. Do you get bruising or persistent bleeding following injury, tooth
Extraction or surgery?
YES   / NO			
2. Do you smoke?
YES   / NO			
3. Have you ever had any infectious diseases including HIV, hepatitis or CJD?			
YES   / NO			
4. Have you ever had heart surgery?
YES   / NO			
5. Have you ever had heart problems, angina, blood pressure problems, stroke or pacemaker?			
YES   / NO			
6. Have you ever had a bad reaction to general or local anaesthetic?(please state which)			
YES   / NO			
                                                                                           (Please turn over)
7. Have you ever had rheumatic fever or chorea (St Vitus Dance)?			
YES   / NO			
                                                                                                                
 8. Have you ever suffered from liver disease (E.g. jaundice, hepatitis) or kidney disease?
YES   / NO			
9. Have you ever had any other serious illness or infectious disease?
YES   / NO			
10. Have you ever had blood refused by the Blood Transfusion Service?
YES   / NO			
11. Have you ever had a joint replacement or other implant?
YES   / NO			
12. Have you ever had treatment that required you to be in hospital?
YES   / NO			
13. Have you ever had brain surgery?
YES   / NO
14. Is there any possibility that you could be pregnant?
YES   / NO
15. Are you taking medicines or Drugs from the doctor?
  YES   / NO
If yes, What are they and why are you taking them?
………………………………………………………………………………………………
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16. Do you have any allergies? E.g. latex, penicillin, antibiotics etc.?
                                                                                                         YES  / NO
                                                                       			
If yes, What are you allergic to?
………………………………………………………………………………………………

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17. Are you happy to be contacted about your appointments by phone,email,letter?
  YES   / NO

Sign:  .................................

Date:  ……………………...