This questionnaire provides the information your dentist needs for your dental treatment and oral health care.
Preferred Title MRMRSMISSMSDRPROF
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
Do you have any of the following symptoms? (Please tick Yes or No)
Sore throat NoYes
Cough NoYes
Fever NoYes
Cold -like symptoms NoYes
Shortness of breath NoYes
Loss of taste &/or smell 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.
Signed by: PatientParentGuardian
Date:
