Medical Questionnaire Medical Questionnarie Step 1 of 3 33% PATIENT FAMILY DETAILS / CONFIDENTIALName*Address*Date of BirthHome PhoneBusiness PhoneMobile PhoneEmail* RESPONSIBILE PARTY DETAILSThe Patient is a minor (under 18 years)*YesNoLiving with MotherYesNoMother's NameAddressHome PhoneBusiness PhoneMobile PhoneEmail Living with FatherYesNoFather's NameFather's AddressHome PhoneBusiness PhoneMobile PhoneWho is responsible for payment of accounts?Who can we thank for referring you to our practice?Who is your regular Dentist/Dental Nurse ?What is your school or place of work? MEDICAL HISTORY QUESTIONNAIREAre you being treated for anything now and if so what?Do you have any allergies?Do you carry a special health card or bracelet?Do you have any of the following problems? Heart problems?*YesNoRheumatic Fever?*YesNoDiabetes?*YesNoFits or Epilepsy?*YesNoAsthma?*YesNoAre you taking any medication for any of the above problems? If so please please list them here:Have you ever had any bleeding problems?*YesNoIf yes, please give detailsHave you any reason to believe that you may be at risk of any infectious or other diseases?YesNoIf yes, please give detailsThe medical history I have given is true and correct to the best of my knowledge* Yes
