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Medical history form

Details

Part 1 of 4

Surname *

First name(s) *

Sex *

Male

Female

Other

Date of birth *

Is the patient’s weight likely to be more than 22 st/140 kg? *

Yes

No

NHS number

Address *

Postcode *

Email * A copy of this form will sent to this email address.

Home telephone number

Mobile number

Is the patient happy to receive SMS (text) notifications?

Yes

No

Where have you lived in the past 12 months? *

Occupation or school *

Next of kin name

Contact telephone number

Relationship of next of kin to the patient

Doctor’s name, address & telephone number

Do you have a social worker?

Yes

No

Please give a name & telephone number

Do you have a Lasting Power of Attorney for health?

Yes

No

How long is it since you last received dental treatment?

Where was this?

Last updated: July 15, 2025*

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Royal Devon and Exeter Hospital (Wonford),
Barrack Road, Exeter,
EX2 5DW
Tel: 01392 411611
North Devon District Hospital,
Raleigh Park, Barnstaple,
EX31 4JB
Tel: 01271 322577

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