This questionnaire provides the information your dentist needs for your dental treatment and oral health care.
Preferred Title MRMRSMISSMSDRPROF
Surname First names
Email Address (es)
Date of birth
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?
Heart Murmur NoYes
Rheumatic Fever NoYes
Open heart surgery NoYes
High blood pressure NoYes
Chest & lung disease NoYes
Sinus/hay fever NoYes
Kidney problems NoYes
Gastric problems NoYes
Depressive illness 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 been in hospital or had surgery in last 12 months? 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.
COVID Risk Assessment Questions*These questions must be answered before we can schedule your appointment*
Have you had one, two or three vaccinations? NoneOneTwoThree
1. Have you or any member of your household had COVID-19 in the last 14 days? NoYes
2. Are you required to self-isolate? NoYes
3. Have you or any family member arrived from overseas in the last 14 days? NoYes
4. Do you have ANY of the following symptoms now, or in the last 14 days?
• Fever, acute cough or shortness of breath NoYes
• Muscle aches, loss of smell, sore throat NoYes
• Generally feeling unwell with no other likely diagnosis NoYes
5. Do you have any other reason to think that you are at risk of having COVID-19? NoYes