Opening Hours
Mon-Fri: 9am - 5pm
15 Castlemaine St
Athlone, Ireland
0906455028
info@athlonedental.ie
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Home
About Us
Treatments
General Dentistry
Dental Hygiene
White Fillings
Cosmetic dentistry
Dental Implant
Teeth whitening
Snoring
Clear Aligners
Root Canal Treatment
Dentures
The Wand® Painless Injection
Fees
Testimonials
Contact
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Medical History Form
Name
First
Last
Medical History
Have you any issues with your heart/blood pressure? e.g.
heart attack
congenital heart defect
stents placed
high cholesterol
blood pressure issues
pacemaker
Please check all that apply to you
liver or kidney issues
Do you or have you ever taken bisphosphonates or antiangiogenic medications
ever had sedation therapy to the head and neck
taken steroids in the past two years
ever had a surgery or operation
ever been hospitalised for any reason
ever had a reaction to a local anaesthetic
Do you faint?
Hypo/Hyperthyroidism
Have you any issues with your lungs? E.g. asthma, bronchitis, emphysema, COPD, history or T.B
(Required)
Yes
No
Please describe
Have you any digestive/stomach issues e.g. gastric reflux?
(Required)
Yes
No
Please describe
Have you any musculoskeletal issues? E.g. arthritis, osteoporosis, previous or planned joint replacements?
(Required)
Yes
No
Please describe
Do you have a bleeding disorder e.g. VWD or heamophilia or a history of prolonged bleeding or are you taking anticoagulants or antiplatlet meds?
(Required)
Yes
No
Do you or does anyone in your family have diabetes?
(Required)
Yes
No
Comment
Do you have epilepsy or a seizure disorder?
(Required)
Yes
No
Comment
Are you or do you think you could be pregnant? Or are you breastfeeding?
(Required)
Yes
No
Do you have any allergies? E.g. penicillin, latex, metals, kiwi, etc?
(Required)
Yes
No
Please describe along with reaction type
Who is your Doctor (GP)? When was your last visit to your Doctor (GP)?
Do you attend any hospital consultants/specialists?
(Required)
Yes
No
Please list
Please list all current medications including prescribed and non-prescribed medications.
Would you like to disclose any other health issues to your Dentist?
Dental & Lifestyle Questions
Do you smoke?
(Required)
Yes
No
What do you smoke/how much/how often?
Do you drink alcohol?
(Required)
Yes
No
How much/how often?
Do you take any recreational drugs?
(Required)
Yes
No
Are you nervous /anxious about attending the dentist?
(Required)
Yes
No
Why / what makes you nervous about your visit?
Is there anything your dentist should know to make your visits more comfortable/easier?
Have you ever had dental treatment under sedation/general anaesthetic?
(Required)
Yes
No
How often do you brush your teeth?
Do you use an electric or manual toothbrush? How old is your toothbrush? Is your toothbrush medium/hard/soft?
Do you use anything to clean between your teeth, E.g Floss, ID brushes? How often?
Do you use any other adjuncts to maintain hygiene? E.g mouthwash
Yes
No
When was your last dental visit?
