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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)





Date of birth


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?


Heart Murmur NoYes

Rheumatic Fever NoYes

Open heart surgery NoYes

High blood pressure NoYes

Stroke NoYes


Asthma NoYes

Chest & lung disease NoYes

Sinus/hay fever NoYes


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: