PLEASE CIRCLE YOUR ANSWERS

Please complete all questions, they are very important

GENERAL DETAILS

First name:	Title:
Surname:	Date of Birth
Sex:
Address



Post Code		Home Tel no:
Work Tel no:		Mobile no:

1. Eventually we will be using text manager to remind you of your appointment, would you like to be reminded in that way?

Yes

2. Would you like email reminders for your appointments?	Yes	No
Email Address:

Previous Name:
Occupation:
Work address:

Post code:
Doctors Name:
Address:

Do you receive any benefits which will effect you having to pay for your treatment (e.g. working family tax credit)

Yes

If your answer is yes please write which type you receive

Dental History

3. Do you go to the dentist

6monthly

12 monthly

Never

Only when having pain?

4. Previous dental history?

Name of Dentist

Approximate date of the last visit

Reason for change of dentist

5. Have you got any problems your previous dentist was watching?

Yes

6. What made you chose us as your new dentist?

Sign at front of practice

Recommendation

Yellow pages

other

7. Would you say you have (please tick accordingly),

A low risk of having fillings.

A filling every so often.

A filling, every time you visit the dentist.

More than one Filling,

8. Is there anything your last dentist did that you particularly liked?

9. Has anyone ever showed you how to brush your teeth properly?

Yes

10. Have you had any of the following treatments?

Crown	Yes	No
Root treatment	Yes	No
Surgical treatment	Yes	No
Gum disease	Yes	No
Periodontal disease	Yes	No
Denplan or Bupa	Yes	No
Specialist treatment	Yes	No
Extractions	Yes	No
Toothache	Yes	No

Family History

11. Did your parents loose their teeth at a young age?	Yes	No
12. Are your parents frightened of going to the dentist?	Yes	No

DID YOU KNOW?

NHS Registration only last for 15 months after this the NHS removes you from our list. Normally we send out a letter telling you of this fact.

Late, if you are 10mins late this will more often than not make us rebook the appointment; this is due to the fact we do not like to rush our work.

Failure to an appointment

If you fail to attend an appointment during your first course of treatment, your deposit will be retained.

Two (2) failed appointments in 2 years will result in the removal from our patient list.

Social History

Marital status

Will your partner require a dentist at their practice

Yes

Do you have any children?			Yes	No
Will they require to be seen at this practice?			Yes	No

Occupation

Do you require dentures?

Yes

If you require dentures then please contact the desk because we would like to give you information to read before you see the dentist.

The practice has private evening appointments available. Will you be interested in taking advantage of these appointments

Yes

Medical History Questionnaire

PLEASE CIRCLE YOUR ANSWERS

1. Do you experience chest pain upon exertion (Angina)?

Yes, Please complete the other questions in this section

No, Please continue to question 2

� Have you had to reduce your activity?	Yes	No
� Have the complaints increased recently?	Yes	No
� Do you have chest pain at rest?	Yes	No

2. Have you ever had a heart attack?

Yes, Please complete the other questions in this section

No, Please continue to question 3

� Do you still have complaints?

Yes

� Have you had a heart attack in the last 6 months?

Yes

3. Do you have a heart murmur or heart valve dysfunction, or an artificial heart valve?

Yes, Please complete the other questions in this section

No, Please continue to question 4

� Have you had heart or vascular surgery within last (6) six months?	Yes	No
� Have you ever had a rheumatic fever?	Yes	No
� Do you have complaints connected with your heart?	Yes	No

Please list the complaints?
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4. Do you have heart palpitations without exertion? If so,

Yes, Please complete the other questions in this section

No, Please continue to question 5

� Do you have to rest, sit down or lie down during palpitation?	Yes	No
� Are you short of breath or pale or dizzy at these times?	Yes	No

5. Do you have problems lying flat?

Yes, Please complete the other questions in this section

No, Please continue to question 6

� Do you need more than two pillows at night due to shortness of breath?

Yes

� Are you short of breath at night lying down?

Yes

6. Have you ever had high blood pressure?

Yes

No

7. Do you have a tendency to bleed?

Yes, Please complete the other questions in this section

No, Please continue to question 8

� Do you bleed for more than (1) one hour following injury or surgery?	Yes	No
� Do you suffer spontaneous bruising?	Yes	No

8. Do you have epilepsy?

Yes, Please complete the other questions in this section

No, Please continue to question 9

� Is your condition getting worse?	Yes	No
� Do you continue to have attacks?	Yes	No

9. Do you suffer from asthma?

Yes, Please complete the other questions in this section.

No, Please continue to question 10

� Do you use inhalers?	Yes	No
� Is your breathing difficult today?	Yes	No

10. Do you have other lung problems?

Yes, Please complete the other questions in this section

No, Please continue to question 11

� Are you short of breath after climbing 20 steps?	Yes	No
� Are you short of breath getting dressed?	Yes	No

11. Have you ever had an allergic reaction or an adverse reaction to dental or medical materials or drugs?

Yes, Please complete the other questions in this section

No, Please continue to question 12

� Was it during the dental visit?

Yes

What are you allergic to?��..

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12. Do you have Diabetes?

Yes, Please complete the other questions in this section

No, Please continue to question 13

� Are you taking insulin?	Yes	No
� Is your diabetes poorly controlled today?	Yes	No

13. Do you suffer from thyroid disease?

Yes, Please complete the other questions in this section

No, Please continue to question 14

� Is your thyroid gland over reactive?	Yes	No
14. Do you suffer from liver disease?	Yes	No

15. Do you have a kidney disease?

Yes, Please complete the other questions in this section

No, Please continue to question 16

� Are you undergoing haemodialysis?	Yes	No
� Have you had a kidney transplant?	Yes	No

16. Have you ever had a malignant disease or leukaemia?

Yes

17. Have you ever had a drug therapy or bone marrow transplant?

Yes

18. Have you ever had an x-ray treatment for a tumour or growth in the head or neck?

Yes

19. Are you suffering from an infectious disease at the moment?

Yes

20. Do you suffer from hyperventilation?

Yes

21. Have you ever fainted during dental or medical treatment?

Yes

22. Do you need antibiotic prophylaxis before dental treatment?

Yes

23. When you cut yourself, do you stop bleeding quickly?	Yes	No
24. Are you pregnant?	Yes	No

25. Are you on medication at present?

Yes

For a heart complaint?

Yes

Anticoagulants

Yes

For high blood pressure?

Yes

Aspirin or other painkillers?

Yes

For an allergy?

Yes

For diabetes?

Yes

Prednisone, corticosteroid (systemic or topical)

Yes

Drug against transplant rejection?

Yes

Drugs against skin, bowel or rheumatic disease?

Yes

For cancer or blood disease?

Yes

Penicillin, antibiotics or ant microbial?

Yes

For sleeping disorder depressive condition or anxiety state?

Yes

Have you ever used recreational drugs?

Yes

Please list your medication below (if there is not enough room for your medication please continue over leaf)

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You should be aware that until you have had your initial examination, you are not covered for any emergency work under the N.H.S. service. If you do require emergency treatment then we can offer a private option, please contact the practice.

From time to time we make �Courtesy Calls� to our patients. These calls are normally to remind patients of future appointments. Your signature below confirms that you have no objection to these calls and that it is in order to leave messages for you.