Call us: 537 4641

Questionnaire

This questionnaire provides the information your dentist needs for your dental treatment and oral health care.

    Preferred Title

    Surname First names

    Address Postcode

    Email Address (es)

    Telephone

    Home

    Work

    Mobile

    Date of birth

    Occupation

    When did you last visit a dentist?

    Are you in self isolation? due to Coronavirus

    If you are under 16, please give name and address of parent/guardian

    Do you have dental insurance cover? NoYes

    Name of your doctor/GP

    Do you smoke? NoYes

    Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to understand a blood test. Do you agree to a confidential blood test? NoYesI wish to discuss this with dentist

    In order to provide the best and safest dental treatment, your dentist needs to know of any medical problems, which may affect your treatment.

    Have you ever had any of the following?

    Cardiovascular:

    Heart Murmur NoYes

    Rheumatic Fever NoYes

    Open heart surgery NoYes

    High blood pressure NoYes

    Stroke NoYes

    Respiratory:

    Asthma NoYes

    Chest & lung disease NoYes

    Sinus/hay fever NoYes

    Other:

    Epilepsy NoYes

    Diabetes NoYes

    Kidney problems NoYes

    Gastric problems NoYes

    Depressive illness NoYes

    Radiotherapy NoYes

    Are you taking any tablets, medicines, pills or drugs? If yes, please list.

    Have you ever had any allergies to medicines, or other substances, (such as Latex)? If so, please list.

    Do you have an artificial or prosthetic joint? NoYes

    Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time? NoYes

    Have you ever had contact with:

    HIV virus NoYes

    Hepatitis B virus NoYes

    Hepatitis C virus NoYes

    Have you ever had an unfavourable reaction to an anaesthetic?NoYes

    Women: Are you pregnant now? If so, how many weeks?

    Are there any other health matters you need to talk to the dentist about?

    I confirm that the information written above is true and correct to the best of my knowledge.I confirm that the information written above is true and correct to the best of my knowledge.

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    Pre Appointment patient assessment Re:Covid-19
    *These questions must be answered before we can schedule your appointment*

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    Do you have a confirmed diagnosis of COVID-19? NoYes

    Are you waiting for a COVID-19 test or the results? NoYes

    Have you travelled overseas in the last 14 days, or had contact with someone who has returned from overseas in the last 14 days? NoYes

    Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID-19? NoYes

    Do you have any of the following symptoms?

    Cough NoYes

    Sore throat NoYes

    Shortness of breath NoYes

    Runny nose, sneezing, post-nasal drip (coryza) NoYes

    Loss of smell (anosmia) NoYes

    If yes, with or without fever? withoutwith

    *If answered yes to any of these please call us on 09 5374641.

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    Signed:
    PatientParentGuardian

    Date: