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Medical History Questionnaire



    Medical Doctor


    How did you hear about us:


    Do you suffer from any of the following?

    High blood pressureHeart ailmentRheumatic feverAsthma, chest or breathing problemsTuberculosisStomach or bowel problems (eg ulcer)Kidney diseaseDiabetesDepression (needing medication)Excessive bleeding or blood disorderEpilepsyHepatitisAIDS/HIVOsteoporosis or bone tumour


    Do you smoke:

    Would you like to discuss these questions in private with the dentist?

    Do you have an artificial hip, heart valve or other prosthetic implant?

    Have you ever had problems with dental treatment?

    Are you presently under medical care?


    Are you taking any drugs, medicines or tablets?


    Female patients, are you pregnant?


    Do you have allergies?


    Type the characters you see above:

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    Medical History Questionnaire

    We aim to deliver quality contemporary dental care that’s tailored to each individual patient’s needs.

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