Name
TITLE
FORENAME
SURNAME
MIDDLE NAME
Date of birth:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
GENDER
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MOBILE PHONE
HOME PHONE
EMAIL
example@example.com
EMERGENCY CONTACT NAME
PNONE NUMBER
RELATIONSHIP
DOCTOR'S NAME
PHONE NUMBER
SURGERY NAME
Are you currently: (If YES give details)
Receiving treatment from a doctor, hospital or clinic?
Yes
No
If YES give details:
Taking any prescribed medications, injections or recreational drugs? (Please supply names)
Yes
No
Drug names
Do you carry a warning card?
Yes
No
If YES give details:
Could you be pregnant or are you breast feeding?
Yes
No
If Yes Due/Birth date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Do you smoke or chew tobacco?
Yes
No
If YES how much?
If you are an ex smoker when did you stop?
How much did you smoke?
Do you vape?
Yes
No
If YES how much?
How many units of alcohol do you consume in a week?
1 unit = A Glass of Wine, a measure of spirit or ½ a pint of beer.
Do you or have you ever had: (If YES please give details)
Allergies to medicines (eg. Penicillin), Substances (eg. Latex) or foods?
Yes
No
If YES give details:
Bronchitis, asthma or other chest condition?
Yes
No
If YES give details:
Fainting attacks, giddiness, blackouts or epilepsy?
Yes
No
If YES give details:
Heart Problems, angina, high blood pressure or stroke?
Yes
No
If YES give details:
Diabetes (or anyone in your family)?
Yes
No
If YES give details:
Bone or joint disease?
Yes
No
If YES give details:
Bruising or persistent bleeding following injury, tooth extraction or surgery?
Yes
No
If YES give details:
Liver disease (eg. jaundice, hepatitis or kidney disease)?
Yes
No
If YES give details:
Blood refused by the Blood Transfusion Service?
Yes
No
If YES give details:
A bad reaction to general or local anaesthesia?
Yes
No
If YES give details:
Treatment that required you to be in hospital?
Yes
No
If YES give details:
Heart surgery?
Yes
No
If YES give details:
Any mental illness?
Yes
No
If YES give details:
Is there anything else that you feel the dentist should know?
COVID - 19
In the past 7 days have you or in the past 14 days has a household member:
Developed a new persistent cough?
Yes
No
Developed a temperature over 37.8C or a fever?
Yes
No
Developed an altered or loss of taste or smell?
Yes
No
Travelled from a different country in the last 14 days?
Yes
No
Are you or a member of your household self-isolating?
Yes
No
Are you or a member of your household COVID vulnerable?
Yes
No
Do you have COVID-19 or awaiting a COVID-19 test?
Yes
No
Form completed by:
Patient
Parent
Guardian
Signed
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Preview PDF
Submit
Should be Empty: