1. Attending, or receiving treatment from, your doctor, hospital, clinic or specialist? yesno
2. Taking any medicines, including tablets, creams, ointments, injections or other? yesno
3. Allergic or sensitive to any medicines (e.g. penicillin) or materials (e.g. latex)? yesno
4. Pregnant or a nursing mother? If so, please give expected date of delivery/date of birth. yesno
1. Had rheumatic fever or chorea (St Vitus dance)? yesno
2. Had jaundice, liver or kidney disease, or hepatitis? If the latter, do you know which type (e.g. A/B/C)? noABC
3. Ever been told you have a heart murmur, heart problem, angina, high blood pressure, or have you had a heart attack? yesno
4. Had any blood tests or inoculations in the last twelve months? yesno
5. Ever had your blood refused by the Blood Transfusion Service? yesno
6. Ever been counselled/tested or been at risk of HIV/AIDS infection? yesno
7. Had a bad reaction to a general or local anaesthetic? yesno
8. Had a joint replacement? yesno
9. Been hospitalised? If "yes, what for and when
10. Ever been advised to take antibiotics before dental treatment (except for the treatment of dental infection)? yesno
1. Have arthritis? yesno
2. Have a pacemaker, or have you had any form of heart surgery? yesno
3. Suffer from hay fever, eczema or any other allergy? yesno
4. Suffer from bronchitis, asthma or any other chest condition? yesno
5. Have fainting attacks, giddiness, blackouts or epilepsy? yesno
6. Have diabetes? yesno
7. Bruise easily or, following a tooth extraction, surgery or injury, have you bled abnormally? yesno
8. Ever get cold sores (herpes)? yesno
9. Suffer from any infectious diseases? yesno
10. Is there anything else that you would like to mention that might be useful?
11. Suffer from any infectious diseases? yesno
1. Do you smoke any tobacco products? yesno
2. If so how much? approx quantity
3. How many units of alcohol do you drink per week?
4. day approx quantity?
(A unit is a half pint of lager, a single measure of spirits or a single glass of wine.)
5. Your doctor's name and surgery address.
6. Doctors telephone number:
1. Do you have any other family members that attend The Clinic? yesno
2. Who recommended you to come to us for treatment?
3. Is there any other information that would be of value to us in your dental treatment?