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New Patients Medical History Questionnaire

Please fill out the form below

First Name *

Last Name *

Date of Birth

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

Email *

Home Phone *

Mobile

Occupation *

Ethnicity

Do you have or have you suffered from any of the following

Heart Complaints e.g. heart attack, angina, surgery, AF, Pacemaker *

Yes No

Rheumatic fever*

Yes No

Diabetes*

Yes No

Chronic bronchitis, asthma or previous TB or respiratory illness*

Yes No

Epilepsy, fainting episodes or neuro-surgery*

Yes No

Depression/Anxiety or any psychiatric illness*

Yes No

Excessive bleeding or easily bruised*

Yes No

Reaction to local anesthetic*

Yes No

High / Low blood pressure*

Yes No

Are you or could you be pregnant at present*

Yes No

Have you been treated with hydrocortisone or cortico-steroids*

Yes No

Do you carry a medical warning card*

Yes No

In the past have you had any surgeries*

Yes No

Any other serious illness not mentioned above*

Yes No

Do you have any allergies to medicines or anything else*

Yes No

Are you HIV positive*

Yes No

Have you ever been diagnosed with Hepatitis?*

Yes No

Investigated for any blood borne or infectious diseases*

Yes No

Any dermatological-skin/scalp conditions (eczema/psoriasis) / Alopecia*

Yes No

Any recent injuries/accidents (fracture or muscular injuries)*

Yes No

If you answered yes to any of the previous questions, please explain the details below:

Are you at present taking any medication?*

Yes No

if so please state name and dose:

Your approximate Weight

Your weekly alcohol consumption? (Units)

If you smoke on average how many cigarettes do you have a day

Do you have any health concerns or conditions that you would like to notify us about?

Name & Address of your GP

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

NHS Number

NB: Please keep us informed of any changes to your health.

I opt-in to receive communication from FACEMED such as appointment reminders, important notifications and Centre news.*

Yes No

Please agree with the FACEMED Privacy Statement.*

I agree with the FACEMED Privacy Statement

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Telephone:

01268 833680

Email:

enquiries@facemed.co.uk

Address:

FACEMED Cosmetic Medical & Dental Centre
Crays Hill
Billericay
Essex
CM11 2XP

Crays Hill,
Billericay,
Essex,
CM11 2XP

Opening Hours
Mon to Fri: 8am – 6pm
Sat: 8am – 2pm

Out of Hours Service: For any dental emergencies, please contact The247Dentist for assistance.

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