Personal Details& Medical History Please enable JavaScript in your browser to complete this form.Personal Information *MrMrsMsMissMstDrName *FirstLastPreferred nameDate of Birth *PhoneWe will not contact you without good reason. Please find our data policy on our 'About' page.Mobile Phone *We will not call you without good reason. Please enter 07000000000 if you have no mobile phone.Email *We will not email you without good reason. Please enter NIL if you have no email address or do not wish to give us one.Address *Post Code *Next of kin or proxy *Proxy/Next of Kin's best contact number *Proxy consent *I consent to my medico-dental record being discussed with my next of kin or proxy named above.Medical History *I consent to electronically submitting my medical history.Covid Vaccination *I am fully vaccinated against Covid-19I am partially vaccinated (first dose only) against Covid-19I have not been vaccinated against Covid-19Not vaccinated reasonMedical Treatment (copy)I am currently receiving treatment from a doctor, hospital or clinicMedical TreatmentMedicationI am taking regular/prescribed medicationMedication Medical Warning CardI currently carry a medical warning cardMedical Warning CardPregnancyI am pregnant or possibly pregnantAllergiesI have allergies to medicines (e.g. antibiotics), substances (e.g. latex/rubber) or certain foodsAllergiesDiabetesI suffer from Diabetes Type 1I suffer from Diabetes Type 2Hay Fever / EczemaI suffer from hay fever or eczemaHay fever / EczemaFaints / EpilepsyI suffer from fainting attacks, giddiness, blackouts or epilepsyFaints / EpilepsyBreathing DisordersI suffer from bronchitis, asthma or another chest conditionBreathing DisordersArthritisI suffer from arthritisBleeding IssuesI either suffer from a blood clotting disorder, take blood thinners, easily bruise or persistently bleed following injuries, dental extractions or surgeriesBleeding IssuesSmokingI smokeSmokingInfectious DiseasesI am HIV positiveI am Covid-19 positive right nowI have had another infectious disease like, for example; hepatitisInfectious DiseasesHeart ConditionI have had heart surgery or a heart problem, angina, blood pressure problems, stroke or a pacemakerHeart ConditionAnaesthetic ReactionsI have had a bad reaction to general or local anaestheticsAnaesthetic ReactionsRheumatic Fever / AB CoverI have had rheumatic fever or chorea (St Vitus' Dance)Liver / Kidney IssuesI suffer from either liver disease (E.g. jaundice, hepatitis) or kidney diseaseLiver / Kidney IssuesAlcoholI drink alcoholAlcoholRefused DonorI have had my blood refused by the Blood Transfusion ServiceRefused DonorJoint ReplacementI have had a joint replacement or other implantJoint ReplacementOsteoporosisI have been diagnosed or am being treated for Osteoporosis or another bone disorderOsteoporosisHospitalisationI have had treatment that required me to be in hospitalHospitalisationBrainI have had a brain injury or brain surgeryBrainMental HealthI suffer with a mental health issueMental HealthOther DiseasesI have another serious illness not already mentionedOther DiseasesCommentSubmit
