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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: