Medical History Questionnaire Please enable JavaScript in your browser to complete this form.Name and Date of Birth *Email *Please enter your email, so we can follow up with you.Full Address *Your doctors surgery is:Are you allergic to any food/medication? If yes, please explain below: *Are you taking any medication? If yes, please list below: *Please tick if you have suffered from any of the following? *Heart condition/diseaseDiabetesEpilepsyChronic bronchitisAsthmaHepatitis CHepatitis BHIV positive Mouth cancerHigh blood pressureExcessive bleedingPace makerImmune system deficiencyTaking Alendronic Acid.Surgery in past 2 yearsSensitivity to lightSleep apnoeaDo you use fluoride toothpaste?YesNoDo you floss your teeth?YesNoDo you use electric toothbrush?YesNoDo you take medicines containing sugar?YesNoSugary/Acidy/Diet fizzy drinks?YesNoSugary treats between meals?YesNoSugary treats before bedtime?YesNoAs far as you know do you grind your teeth?YesNoWebsiteSubmit
