Medical History

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Medical History

Confidential Medical History Form

We are looking forward to welcoming you to the Park Practice. At present our registrations will be on a non NHS basis.

Personal Details

Title *

First Name *

Last Name *

Date of Birth

Sex

Occupation

Home Phone

Work Phone

Mobile Phone *

Address Line 1

Address Line 2

Town/City

Postcode

Email Address *

Location

Why did you choose The Park Practice?

Where/When was your last dental treatment?

Medical Questions

Are you attending or receiving treatment from a doctor, Hospital, clinic or specialist?

Are you taking any medicines from your doctor? (tablets, ointments, injections or inhalers)

Are you allergic to any medicines, food or materials?

Are you concerned about any aspects of your health you think your dentist should know about?

Do you smoke? If Yes, how many cigarettes per week?

Do you drink alcohol? If Yes, what is your average weekly intake?

Have you had any problems with your Heart?

Have you had any problems with your Blood Pressure?

Have you had any problems with Bronchitis, Asthma or any other chest condition?

Have you had any problems with your Liver?

Have you had any problems with Fainting Attacks?

Have you had any problems with Bleeding after surgery or tooth extraction?

Have you had any problems with Headaches/Migraines, neck or back pain?

Have you had any problems with Diabetes?

Please tick this box to confirm that all above information is accurate*

To comply with data protection regulations (2018), we are unable to store and use your information unless you give us your permission. Please select Yes to allow this. View our data protection policy for details.*

* fields are mandatory

Opening Hours

MON

8.30am - 6.30pm

TUES

8.30am - 6.30pm

WED

8.30am - 5.30pm

THU

8.30am - 6.30pm

FRI

8.30am - 4.30pm

SAT & SUN

CLOSED

0141 334 1211
enquiries@parkpracticehealth.co.uk
The Park Practice
61 Park Road
Glasgow
G4 9JE

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