Title: first names: surname



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TITLE: FIRST NAMES: SURNAME:

DATE OF BIRTH: HOME TEL.NO: WORK / MOBILE:


**If your address details have changed since registering with the practice, please

ensure that our reception team have been updated with all the relevant details. **

Confidential Medical History Form






YES

NO

DETAILS

ARE YOU IN GOOD HEALTH










ARE YOU PREGNANT?











DO YOU HAVE, OR HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?

HEART PROBLEMS Heart Attack, Stroke, Heart Murmur, Angina, Pacemaker, Congenital heart problem, Rheumatic Fever, High/Low Blood Pressure?










CHEST PROBLEMS, ASTHMA OR BRONCHITIS?










HEPATITIS OR JAUNDICE?










HAVE YOU HAD SURGERY OR BEEN ADMITTED TO HOSPITAL IN THE LAST 12 MONTHS? Please detail










ANY BLOOD DISORDERS Anaemia, Leukaemia, HIV/AIDS, Haemophilia. Following tooth extraction, surgery or injury have you bled so as to cause you to be worried










HAVE YOU BEEN DIAGNOSED WITH ANY OTHER SERIOUS ILNESS










EPILEPSY Black outs/fainting attacks










DIABETES Low blood sugar










COLD SORES OR MOUTH ULCERS












ARE YOU PRESENTLY TAKING ANY DRUG, MEDICATION OR ANY OF THE FOLLOWING?


ANTIBIOTICS










PAINKILLERS










TRANQUILLISERS Antidepressants, sedatives, sleeping pills










ANTICOAGULANTS (blood thinners including Aspirin)










DRUGS FOR HEART/CHEST PROBLEMS high blood pressure










STEROID THERAPY










PLEASE LIST ANY OTHER DRUG OR MEDICATION YOU ARE CURRENTLY TAKING INCLUDING SELF MEDICATED.

DO YOU SUFFER FROM ANY ALLERGIES TO MEDICINES (EG PENICILLIN), SUBSTANCES, (EG LATEX/RUBBER) OR FOODS?

DO YOU SMOKE or HAVE YOU EVER SMOKED? IF SO APPROX HOW MANY DAILY?









DO YOU DRINK ALCOHOL? IF YES HOW MANY UNITS WEEKLY?










Signature: Date:

At The Savernake Forest Dental Practice we ask our New Patients joining the practice to complete a questionnaire, this helps us to provide the best care and treatment for you.




TITLE: FIRST NAMES: SURNAME:

DATE OF BIRTH: TEL:



HOME ADDRESS:

POSTCODE: E-MAIL.

OCCUPATION:

HOW DID YOU HEAR ABOUT THE PRACTICE? Friend Family Member Yellow Pages Ad Web Dentist

WHOM MAY WE THANK FOR INTRODUCING YOU?

YOUR DOCTOR’S NAME: TEL.NO.

YOUR DOCTOR’S ADDRESS: POSTCODE:





Optional Questions

Please write details below

How often do you brush your teeth and for how long?




How often do you floss or use other inter-dental products?



When brushing your teeth do you ever have any bleeding from the gums?



Do you have any current concerns with your teeth?




Would you consider yourself as a nervous dental patient?



What makes you nervous when you visit the dentist?




When did you last visit the dentist?




Have you ever seen a hygienist? If Yes please give details.




Do you have any Crowns/Bridges/Implants or Dentures? If Yes please give details.




Are you happy with your smile?




If not would you like to discuss the options available to you?




We offer teeth whitening, is this something you would like to discuss?




We offer teeth straightening, is this something you would like to discuss?




Would you like to receive our newsletter and other practice updates by email?





Signature: Date:


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