New Patient Questionnaire

Medicines and current state of your health

Covid-19 (Coronavirus)

IMPORTANT: Have you had any of the following in the past 14 days?

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Persistent cough
Shortness of breath or difficulty breathing
Temperature above 38 degrees
Any symptoms of respiratory tract illness whatsoever
Loss of taste and / or smell
Unexplained tiredness or lethargy
I have been in contact with someone with symptoms but I am asymptomatic
Muscular aches
I have not had any of the above

IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS WE WOULD ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST TWO WEEKS. IF YOU HAVE A DENTAL EMERGENCY PLEASE CONTACT THE PRACTICE SO THAT WE MAY MAKE SPECIAL ARRANGEMENTS FOR YOUR EMERGENCY CARE.

I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus

.

I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly contagious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious.

I am aware of the risks

Yes
No

Would you like our revised safety procedures explained to you or would you prefer to have minimal explanation?

Yes
No

Are you a current smoker or do you currently use other tobacco products?

Yes
No

Please provide details of how much and for how long you have smoked. Please include use of all tobacco products

How many units of alcohol do you drink per week?e.g 2 units for a large glass of wine or a pint.

None
1-10 units
11-20 units
Over 20 units

Are you currently under medical treatment?*

Yes
No

Please provide details:

Are you pregnant?*

Yes
No
Possibly

If you are pregnant, when is baby due? If you are unsure at the moment, by when will you know?*

Are you currently breastfeeding?*

Yes
No

Do you have any physical or mental disability that may impair your ability to understand or consent to care?*

Yes
No

Please provide details:*

Do you have or have you ever had any of the following?

Please provide details:*

Allergies to any of the following (please tick all that apply)

I have no known allergies
Drugs or medicines such as penicillin
Anaesthetics
Contact allergy e.g latex, metals
Food allergy or intolerance
Other

Malignant disease (cancer) that required surgery, chemotherapy and / or radiotherapy

Yes
No

Please provide details*

Breathing problems during sleep / sleep apnoea / snoring

Yes
No

Please provide details*

Are you a carrier of any of the following blood-borne viruses: HIV, Hepatitis B, Hepatitis C?

Yes
No

Please provide details*

Do you take any prescription medications?

Yes
No

Please list all the medicines or drugs (prescribed, over the counter or self medication) you take on a regular basis (including contraceptive pills, recreational drugs). If possible, please include dosages and frequency.*

Please add anything else you feel may be of medical importance

Personal details and contact information

Medicines and current state of your health

Covid-19 (Coronavirus)

Dental Questionnaire

GDPR and consent

Please read carefully and indicate consent as appropriate

Consent for use of all clinical data held by us