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MEDICAL QUESTIONNAIRE
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MEDICAL
QUESTIONNAIRE
First Name *
Last Name *
Date of Birth
Address 1
Address 2
City
Zip/Postcode
State/Province
Country
Email Address
Mobile Number
Home Number
Did you have rheumatic fever, have a congenital heart disease or had a heart valve replacement or a pacemaker fitted?
Yes
No
Do you have any heart complaints, including murmurs and chest pain (angina)?
Yes
No
Do you suffer from diabetes?
Yes
No
If Yes, please indicate TYPE1 (insulin controlled) or TYPE 2 (diet controlled) below.
Type 1 (insulin controlled)
Type 2 (diet controlled)
Do you suffer from fainting spells, dizziness, seizures or epilepsy?
Yes
No
Do you have asthma or chronic bronchitis?
Yes
No
Do you bruise easily, have abnormal bleeding times or suffer from anemia?
Yes
No
Do you suffer from high blood pressure or take medication to control high blood pressure?
Yes
No
Do you have digestive complaints, e.g. heart burn (acid reflux) or suffer from conditions like bulimia?
Yes
No
Do you carry a Medic Alert warning card or bracelet?
Yes
No
Have you been hospitalised or undergone any surgery in the past 3 years?
Yes
No
Have you ever had a blood transfusion?
Yes
No
Have you been diagnosed with jaundice / hepatitis? If Yes, please indicate type A, B or C below.
Yes
No
If Yes, what kind of Hepatitis?
A
B
C
Are you HIV positive or at risk of contracting HIV?
Yes
No
Have you been advised to take medication before undergoing dental procedures?
Yes
No
Are you suffering from any other serious illnesses?
Yes
No
Have you taken any of the following in the past year?
Antibiotics / sulfa drugs
Anticoagulants / High blood pressure medication
Antidepressants
Insulin or related drugs
Drugs for heart conditions
Do you have allergies or had bad reactions to any of the following?
Local anaesthetic
Penicillin or other antibiotics
Sulfa drugs
Aspirin
Codeine
Iodine
Latex / rubber
Are you pregnant or are you breastfeeding?
Yes
No
Please list ALL the medicines you take, including self-prescribed preparations. Also provide the dosage for your medication.
Do you smoke or use any tobacco products?
Yes
No
If so, how much per day?
1 - 10
11 - 20
20 +
Do you consume alcohol? If so, how many units/day?
< 1
1 - 2
3 - 5
> 6
Are you using any illegal or other recreational drugs?
Yes
No
If Yes, please provide more details in the space below.
Name of your GP
GP's practice name and address, including postcode
GP's telephone number
How long ago did you last visit a dentist?
Choose an option
How long has it been since you visited a dental hygienist?
Choose an option
How did you find out about us?
Choose an option
If other, please specify.
What is your main concern?
I am not happy with my smile.
I am concerned about the effect of my teeth on my personal life and career.
I have bad breath.
I have bleeding gums.
I have sensitive teeth.
I have stained teeth.
I have crooked teeth I want treated.
I can't clean my teeth properly.
I have loose teeth or have missing teeth.
I have broken fillings / teeth / crowns / veneers.
I can't chew properly.
I do not like some of my old fillings / crowns / caps.
I am clenching / grinding my teeth.
My jaw hurts / my wisdom teeth are hurting me.
I am concerned about the effect of the condition of my teeth on my general health.
I am fearful of having dental treatment.
I am concerned over the potential cost of my treatment.
I have other concerns I will discuss with my dentist / hygienist.
For any other concerns, please specify.
I am interested in having a FREE consultation for the following:
Options available to straighten my teeth.
Very often clinical photography forms part of your treatment planning and progress. These images may be used for the purposes of teaching, website, articles or promotional material, in the UK and abroad. Please select one of the boxes below to indicate consent for these images to be used:
I consent to all images being used anonymously under the Data Protection Act 2018.
I consent to all images being used anonymously, apart from images of my face, under the Data Protection Act 2018.
I do not consent to any images being used.
IGDP Limited is a private dental practice. We do not provide treatment on the NHS.
I understand I have to pay for my treatment.
We need at least 48 hours notification if you can't keep an appointment. Failure to do so may result in a professional fee charged at £30/10 minutes. IGDP Limited reserves the right not to provide treatment if you arrive late and we need to reschedule your appointment. You may still be charged for this appointment. If we run late with your appointment, we will offer to reschedule your appointment.
I have read, understood and agree to the terms of my bookings.
Please sign your name.
Clear
SUBMIT
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