Dear Patient,

This form provides the dentist/hygienist/therapist with important information, essential for your Dental treatment and Oral Health Care.

Please complete this form by ticking the appropriate boxes and answering the questions. All details will be strictly confidential and kept in accordance with the Data Protection Act 1998.

Title:
First name: 
Surname:
Dob:
Address:
Postcode:

Home Phone:  
Work Phone:  
Email:

Mobile Phone:

Preferred contact method:

Details of person to contact in an emergency:

Name: ...................................................................................................
Phone Number: .......................................................................................

1. Medical Doctor’s Name or Practice/Telephone Number

Details:................................................................................................................................................................................................................................

2. Are you taking any medication (pills/medicines etc), what are they for? Yes / No

Medication Name/s:..............................................................................................................................................................................................................................

Condition/s:.................................................................................................... ..........................................................................................................................................................................................................................................

3. Do you carry a warning card? Yes / No

Reason:...............................................................................................................................................................................................................................

4. Do you have any ALLERGIES or unusual effects from any medication, latex or anaesthetic? Yes / No

Details:................................................................................................................................................................................................................................

5. Are you, or have you been, under the care of a doctor during the past two years? Yes / No

Reason:……………………………………………………………………………………………………………………………

6. Any prosthetic surgery e.g. Heart Valve or Hip Replacement etc

Details:................................................................................................................................................................................................................................

7. Do you have/ had any of the following? If so, please tick as appropriate.

◌ Rheumatic Fever

◌ Heart Trouble
◌ Epilepsy

◌ Anaemia
◌ Cancer

◌ Bronchitis
◌ Asthma

◌ Cold sores

◌ High Blood Pressure
◌ Diabetes
◌ Chest Problems
◌ Arthritis

◌ Hepatitis
◌ Kidney Trouble
◌ Drug Dependence
◌ Severe Headaches

◌ HIV
◌ Gastric Problems
◌ Depressive Illness

7. Do you drink alcohol? If so, how many units per week? ................ Yes / No

8. Do you smoke? If so, how many cigarettes per day? ................ Yes / No

9. Are you pregnant? If so, how many months: ................ Yes / No

10. Are you breastfeeding? Yes / No

11. Do you have any special needs or disability requirements? Yes / No

12. Do you become anxious or uncomfortable when you are having dental treatment? Yes / No

13. Do you have Dental pain or a Dental problem at present? Yes / No

Details: ..........................................................................................................................................................................................................................................

For confidentiality purposes, are you happy for us to contact/speak/leave message/text/email on details provided? Yes / No

Signed: Patient/Parent/Guardian ..................................................................................................................... Date: .............