Full Name
Title
Ms
Miss
Mrs
Mr
Dr
Title
Home Address
Telephone Number
Email Address
Sex
Male
Female
Other
Occupation
Date of Birth
Doctors Name & Practice Address
Are you attending or receiving treatment from a doctor, hospital or clinic?
Yes
No
If Yes, please submit details.
Have you had any operations or serious illnesses in the past?
Yes
No
If Yes, please submit details.
Are you taking any medicines from your doctor?
Yes
No
If Yes, please submit details.
Allergies to any medicines or materials? e.g. antibiotics or latex?
Yes
No
If Yes, please submit details.
Do you suffer from bronchitis, asthma or any other chest conditions?
Yes
No
If Yes, please submit details.
Ever been told you have a heart problem, angina or high blood pressure?
Yes
No
If Yes, please submit details.
Do you have a pacemaker?
Yes
No
If Yes, please submit details.
Do you have, or have you had, any problems with your blood? e.g. anaemia, sickle cell disease, thalassamia, prolonged bleeding or bruising?
Yes
No
If Yes, please submit details.
Do you have persistent bleeding following injury, tooth extraction or surgery?
Yes
No
If Yes, please submit details.
Have you had Jaundice, liver disease, kidney disease or hepatitis?
Yes
No
If Yes, please submit details.
Do you have any problems with your joints/bones? e.g. arthritis/ osteoporosis?
Yes
No
If Yes, please submit details.
Do you have, or have you had, any problems with your nervous system? e.g. Epilepsy, Parkinson’s, MS, Stroke?
Yes
No
If Yes, please submit details.
Do you have or have you ever had any issues with your stomach or gut? e.g. ulcers, reflux, colitis?
Yes
No
If Yes, please submit details.
Do you suffer from any skin conditions? e.go eczema or psoriasis?
Yes
No
If Yes, please submit details.
Do you have Diabetes?
Yes
No
If Yes, please submit details.
Do you have, or have you ever had cancer?
Yes
No
If Yes, please submit details.
Do you suffer from any infectious diseases (including H.I.V)?
Yes
No
If Yes, please submit details.
Ever had a bad reaction to a general or local anaesthetic?
Yes
No
If Yes, please submit details.
Is there anything else your dentist should know about, such as self prescribed medicines (e.g. aspirin) or treatment/medicines which you may prefer not to have for medical or religious reasons?
Yes
No
If Yes, please submit details.
Do you have any physical disabilities? e.g. wheelchair user, visual, hard of hearing?
Yes
No
If Yes, please submit details.
Do you have a learning disability?
Yes
No
If Yes, please submit details.
Do you have any problems with your mental health? e.g. anxiety, depression, schizophrenia, bipolar, eating disorders?
Yes
No
If Yes, please submit details.
Do you carry a medical warning card?
Yes
No
If Yes, please submit details.
Do you smoke tobacco products now or in the past? If yes, how many a week?
Yes
No
If Yes, please submit details.
Do you drink alcohol? If yes, what is your weekly intake?
Yes
No
If Yes, please submit details.
Are you pregnant?
Yes
No
If Yes, please submit details.
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