Personal Dental Assessment

All patients must complete this medical history…you can do this now in advance or alternatively you can complete it on the day of your appointment at the practice but please arrive 10 minutes prior to your appointment time in order to do so.

All information is confidential and will not be shared with any third party.

Mr Mrs Miss Ms Dr

Full Name
Date of birth
Home Phone
Work Phone
Work Address

Which of the following statements best describes your feelings about visiting the dentist?

I feel relaxed

I feel a little anxious

I feel very nervous

If you could alter your smile what would you most like to change?

When did you last visit your dentist?

We hope you will be satisfied with the care you receive in our practice. We would like to know what made you choose us. Please choose ONE of the following options.

I was recommended by a friend/family member – please specify.

I saw the sign outside

I saw your website.

Internet/Google please specify:

I was given your number by directory enquiries

I saw your number in Golden Pages

Late evening/Saturday appointments

I prefer the option of sedation for treatment

Seen reviews/listing on business web listing.

Other, please specify:

Confidential Medical History

Some medical conditions and medicines used to treat them can affect dental treatment. Please read the following and answer the questions carefully. Thank you.

 YesNoFurther details
1. Attending or receiving treatment from a doctor, hospital clinic or specialist?
2. Taking ANY pills, tablets or medicines from your doctor?
3. Taking or have taken steroids in the last 2 years?
4. Pregnant or nursing?
5. Allergic to ANY medicines. e.g. Penicillin, Aspirin, Local Anaesthetic?
1. A prosthetic heart valve, a history of infective endocarditis, heart transplant or surgery including shunts/conduits or congenital heart disease?
2. Hypertension, angina or pacemaker?
3. Had jaundice, liver, kidney disease or any type of hepatitis?
4. Ever reacted adversely to a General or Local Anaesthetic?
5. Had any serious illness or operation?
6. Ever been refused by the blood transfusion service?
DO YOU?   
1.Suffer from chronic bronchitis, asthma or breathing difficulties?
2.Suffer from giddiness, blackouts or epilepsy?
3.Suffer from diabetes?
4.Easily bleed?
5.Carry a warning card?
6.Have any other aspects concerning your health?