Title: MrMrsMissMs

Full Name:

Sex: MaleFemale

Date of Birth:

Address:

What is your reason for attending the practice:—Please choose an option—New patient consultationBroken toothPainSwellingOther

Please provide further Details if required:

Postcode:

Phone Number:

Your email address:

Occupation:

When did you last receive dental treatment?

Doctors name:

Doctors Address:

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
YesNo

Are you taking any medicines, tablets, drugs or injections or using any cream, ointments or inhalers?
YesNo

Are you taking or have you taken steroids in the last 2 years?
YesNo

Are you allergic to penicillin?
YesNo

Are you allergic to any medicines, foods or materials?
YesNo

Do you carry a warning card?
YesNo

Are you pregnant or a nursing mother?
YesNo

Are you HIV positive?
YesNo

Have you had rheumatic fever or chorea?
YesNo

Have you had jaundice, liver or kidney disease or hepatitis?
YesNo

Have you ever had a stroke?
YesNo

Did you as a child or since have brain surgery, growth hormone treatment before the mid 1980’s or have a close relative with Creutzfeldt Jakob Disease?
YesNo

Have you ever been told you have a heart murmur, heart problem, angina or high blood pressure?
YesNo

Have you ever had your blood refused by the Blood Transfusion Service?
YesNo

Have you ever had a bad reaction to a local or general anaesthetic?
YesNo

Have you had a joint replacement or other implant?
YesNo

Have you been hospitalised for any reason?
YesNo

Do you have arthritis?
YesNo

Do you have a pacemaker or have you had heart surgery?
YesNo

Do you suffer from hay fever, eczema, or any other allergy?
YesNo

Do you suffer from bronchitis, asthma, or chest infection?
YesNo

Do you have fainting attacks, giddiness, blackouts or epilepsy?
YesNo

Do you have diabetes or does anyone in your family?
YesNo

Do you bruise easily or suffer persistent bleeding following a tooth extraction?
YesNo

Do you think there are any other aspects, concerning your health, that your dentist should know?
YesNo

On average, how many of the following do you have on a daily basis?

Cigarettes:
Alcoholic Drinks:

Additional Comments

By submitting my details, I agree to the terms and conditions detailed in the privacy policy.

I understand a minimum of 24 hours notice must be given to change or cancel an appointment. A cancellation fee of 50 percent of your treatment cost will apply if changes are made with less than 24 hours notice or you fail to attend the appointment.

I consent to allow photographs to be used for the following purposes: Dental Records,Treatment planning, Marketing material, including websites and printed materials, patient education.