APPLICATION TO JOIN WOODHALL DENTAL PRACTICE

Personal Details

Title:*

Full Name:*

Address:*

Town:*

County:*

Post Code:*

Tel(H):*

Mobile:*

Email:*

Date Of Birth:*

Select Gender:*

Male

Female

Occupation:*

GP’s Name:*

GP’s Address:*

GP’s Tel:*

Last Dental Visit:*

Are You Currently

In good health?*

Yes

No

Attending or receiving treatment from a doctor, Hospital or Clinic?*

Yes

No

Taking any prescribed medicines? tablets, ointments, injections, HRT*

Yes

No

Taking or taken steroids in the last 2 years?*

Yes

No

Taking any blood thinning medication?*

Yes

No

Wearing a pacemaker?*

Yes

No

Pregnant or nursing mother?*

Yes

No

Carrying a medical warning card?*

Yes

No

Do You Suffer From

Allergies to any medicines, (penicillin) substances, (latex) or foods (nuts)*

Yes

No

Hay fever or eczema?*

Yes

No

Bronchitis, Asthma, or any other chest conditions?*

Yes

No

Fainting attacks, giddiness, black-outs epilepsy?*

Yes

No

Heart conditions, angina, stroke, blood pressure problems?*

Yes

No

Diabetes? (or does anyone in your family?*

Yes

No

Arthritis or other bone or joint disease?*

Yes

No

Thyroid problems? (over or under active)*

Yes

No

Liver or Kidney disease? Or had Jaundice?*

Yes

No

Bruising or persistent bleeding following injury, tooth extraction?*

Yes

No

Any infectious diseases? (including HIV, Hepatitis B, C, or D)*

Yes

No

Have You Ever Had

Osteoporosis?*

Yes

No

Radiotherapy or Chemotherapy?*

Yes

No

A bad reaction to local or general anaesthetic?*

Yes

No

Blood refused by the Blood Transfusion service?*

Yes

No

A joint replacement or other implant?*

Yes

No

Cold sores?*

Yes

No

Rheumatic fever or chorea?*

Yes

No

Growth hormone treatment?*

Yes

No

Treatment that you to be hospitalised?*

Yes

No

Heart or Brain surgery?*

Yes

No

Creutzfeldt Jakob Disease?*

Yes

No

DRINKING, SMOKING & CHEWING

“Do you drink any alcohol? If so, how many units do you drink per week? (One unit is a half pint of lager, a single measure of spirits or a glass of wine)*

Yes

No

Do you smoke any tobacco products, or did you smoke in the past?*

Yes

No

Do you chew tobacco, paan, arecanut, supari or use gutkha?*

Yes

No

Additional Information

Do you think there are any other aspects, concerning your health that your dentist should know about?*

Yes

No

Do you have any communication support needs relating to a disability, sensory loss, or other impairment?*

Yes

No

Do you experience any problems when chewing?*

Yes

No

Are you happy with the overall appearance of your teeth?*

Yes

No

Do your gums ever bleed when you brush?*

Yes

No

How do you feel about going to the dentist?*

Not anxious

Slightly anxious

Very anxious

How would you describe your diet?*

Poor

Average

Excellent

How many times do you brush your teeth?*

Once a Day

Twice a day

After every meal

How often do you clean in between your teeth with floss or interdental brushes?*

Daily

Every other day

Weekly

Never

Covid Screening Questions

Do you currently have a cough?*

Yes

No

Have you had a persistent dry cough in the last 14 days?*

Yes

No

Are you having shortness of breath or difficulty in breathing?*

Yes

No

Do you have a fever or felt feverish in the last 14 days?*

Yes

No

Patient Declaration

Patient Declaration completed by:*

Self

Parent

Guardian

Carer

I consent to the dental provider, or their representative, to examine me and to give me any necessary care and treatment that I am willing to undergo. I agree to pay the charges for the service I receive. I declare that the information I have given on this form is correct and complete to the best of my knowledge.

Signature*

Date*

MEDICAL HISTORY TO BE UPDATED EVERY SIX MONTHS AFTER FIRST EXAMINATION

Please check that the health information on this form is still correct including information on smoking & drinking. If not, please note any changes below.