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?

Name of your last 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: