Patient Questionnaire
TITLE:
FIRST NAME:
SURNAME:
DATE OF BIRTH:
OPTIONAL QUESTIONS
HOME TEL:
MOBILE TEL:
HOME ADDRESS:
HOW OFTEN DO YOU BRUSH YOUR TEETH AND FOR HOW LONG?
TWICE A DAY
ONCE A DAY
WHEN I REMEMBER
MORE THAN TWICE A DAY
HOW OFTEN DO YOU FLOSS OR USE OTHER INTER-DENTAL PRODUCTS?
TWICE A DAY
ONCE A DAY
WHEN I REMEMBER
MORE THAN TWICE A DAY
POSTCODE:
EMAIL:
NHS NUMBER:
(Your NHS number can be requested from your GP, they may ask you for
identification)
OCCUPATION :
IF STUDENT SCHOOL/COLLEGE ATTENDING
YOUR DOCTORS NAME:
DOCTORS PRACTICE NAME:
DOCTORS PRACTICE ADDRESS:
WHEN BRUSHING YOUR TEETH DO YOU EVER HAVE ANY
BLEEDING FROM THE GUMS?
YES
NO
DO YOU HAVE ANY CURRENT CONCERNS WITH YOUR TEETH?
YES
NO
WOULD YOU CONSIDER YOURSELF AS A NERVOUS DENTAL
PATIENT?
WHAT MAKES YOU NERVOUS?
YES
NO
WHEN DID YOU LAST VISIT THE DENTIST?
POSTCODE:
HOW DID YOU HEAR ABOUT THE PRACTICE?
ONLINE
WORD OF MOUTH
YELLOW PAGES
WEBSITE
LEAFLET
OTHER (Please specify)
WHO MAY WE THANK YOU FOR INTRODUCING YOU?
SIGNATURE:
DATE:
HAVE YOU EVER VISITED THE HYGENIST?
IF YOU HAVE ANY CROWNS/BRIDGES/IMPLANTS OR DENTURE PLEASE
LIST:
ARE YOU HAPPY WITH YOUR SMILE?
YES
NO
IF NOT WOULD YOU LIKE TO DISCUSS THE OPTIONS AVAILABLE
YES
TO YOU?
NO
WE OFFER TEETH WHITENING, IS THIS SOMETHING YOU WOULD YES
LIKE TO DISCUSS?
NO
WE OFFER TEETH STRAIGHTENING, IS THIS SOMETHING YOU
YES
WOULD LIKE TO DISCUSS
NO
WOULD YOU LIKE TO RECEIVE OUR NEWSLETTER AND OTHER
YES
PRACTICE UPDATES BY EMAIL?
NO
Medical History
Units of alcohol
1pint=3units, Wine 175ml = 2 unit, Alcopop 1.4 units, single spirit = 1 unit, Bottle wine = 10 units
HABITS
WARNINGS
Pregnant or possibly pregnant
Antibiotic Cover Required
Bruising or persistent bleeding
Currently under Treatment
Y/N
Y/N
Y/N
Y/N
Anything Dentist should know
Y/N
Do not Recline
Steroids within 2 years
Warning card
Treatment Req
Hospitalisation
Y/N
Y/N
Y/N
Y/N
Qty
Smoke (per day)
Chew Tobacco (per day)
Alcohol Units (per week)
Details
HEART
Rheumatic fever
High Blood Pressure
Heart surgery
Pacemaker Fitted
Details
BLOOD
Hepatitis B
H.I.V
Abnormal Blood Test
Blood refused by
transfusion service
Details
ALLERGIES
Penicillin
Hay Fever
Anti Tetanus Serum
Eczema
General Anaesthetic
Local Anaesthetic
Details
High sugar diet
Frequent fizzy drinks
Recreational drugs
Y/N
Y/N
Y/N
Y/N
Heart Murmur
Angina
Thrombosis
Other heart conditions
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Details
CHEST
Bronchitis
Cystic fibrosis
Pleurisy
Asthmatic
Y/N
Y/N
Y/N
Y/N
Emphysema
Pneumonia
Chest surgery
Other chest conditions
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Kidney disease
Epilepsy
Hiatus Hernia
Artificial joint
Giddiness
Cancer
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Details
MEDICATION List
Y/N
Y/N
Y/N
Y/N
Anaemia
Sickle cell
Haemophilia
Other blood conditions
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Latex Allergy
Medicines
Plants
Foods
Aspirin
Other Allergy Conditions
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
OTHER
Liver Disease
Diabetes
Acid Reflux or eating Disorder
Bone or joint disease
Fainting attacks or blackouts
Past serious or infectious
disease
Details
Signature:
.........................................
Date:
.....................................
Name
........................................
NHS number ............................
DOB:
........................