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T: 01394 283419

E: contact@waltonhousedentalpractice.co.uk

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Oral health specialists in Suffolk

YEARS'

EXPERIENCE

Our oral health specialists offer regular dental check-ups as well as efficient dental treatments in Suffolk. Contact Walton House Dental Practice.

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EMERGENCY DENTAL TREATMENT

Your Medical History Form - Book an appointment

Did you, as a child or since, have:

Rheumatic fever or chorea?

Liver disease (e.g. jaundice, hepatitis) or kidney disease?

Any other serious illness?

Blood refused by the blood transfusion service?

Bad reaction to general or local anesthetic?

Joint replacement or other implant?

Treatment that required you to be in the hospital?

Heart surgery?

Please give details

Do you suffer from...

Allergies to any medicines (e.g. penicillin) substances (e.g. latex/rubber) or foods?

Hayfever or eczema?

Bronchitis, asthma or other chest conditions?

Faint attacks, giddiness, blackouts or epilepsy?

Heart problems, angina, blood pressure problems or stroke?

Diabetes (or does anyone in your family)?

Arthritis

Bruising or persistent bleeding following injury, tooth extraction or surgery?

Infectious diseases (including HIV and hepatitis)?

Please give details

Full name (including title)

Male/Female

Date of birth

Address

Postcode

Home phone

Mobile phone

Occupation

Doctor's name

Doctor's address

Doctor's phone

Are you currently...

Receiving treatment from a doctor?

Taking any prescribed medicines (e.g. tablets, ointments, injections or inhalers, including contraceptives/hormone replacement therapy)?

Carrying a medical warning card?

Pregnant?

Please give details

How many units of alcohol do you drink per week?

Do you smoke any tobacco products now (or did you in the past)?

If yes, how many do you smoke a day?

Covid 19- screening questions

Have you been shielding or are you at increased risk or COVID-19?

Have you tested positive for COVID-19 in the last 7 days?

Are you waiting for COVID-19 test result?

Do you have a high fever, continuous cough, lost or change in taste or smell?

Do you live with someone of who has tested positive?

Next of kin name

Next of kin contact number:

Please give any other details which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin)

Sign name:

Date

Completed by (please select):

Self

Parent

Guardian

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COSMETIC DENTISTRY

Young woman getting her teeth examined by dentist

Please call us to book an appointment with our oral health specialists in Suffolk.

01394 283419

CONTACT

T: 01394 283419

E: contact@waltonhousedentalpractice.co.uk

A: 218 High St, Felixstowe, Suffolk, IP11 9DS

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Phone

Your message

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Walton House Dental Practice Ltd, registered as a limited company in England and Wales under company number: 07063891.

Registered Company Address: 218 High Street, Felixstowe, Suffolk, IP11 9DS

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