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Confidential Patient Questionnaire

Start

Confidential Patient Questionnaire

Providing us with the following information allows us to treat you as effectively as possible...

Patients first & last name: (in this order please) *

Patients date of birth: (DD/MM/YY) *

Best contact number for patient: *

Email address - Used for confirming this patients appointment bookings & for any future automatic dental recalls due. -Please note parent/caregivers if patient is under 18years of age *

Patients physical address: NO PO boxes - Required for prescriptions, referrals, ACC claims etc Area CityPost code must all be noted *

Patients Doctor/GP or practice: *

How did you hear of this practice?

Please list allergies inc. medicines, penicillin, latex, mint, local anaesthetic etc. If none - please confirm this noting: "none" below *

Please list all medications inc. herbal/natural supplements, steroids &/or vitamins you/the patient are currently taking/taken recently. If none - please confirm this noting: "none" below *

Please check only those that apply to you/the patient: *

Heart murmur

Heart attack

Heart surgery - inc. Pacemaker fitted

High blood pressure

Rheumatic fever

Asthma

Chest &/or lung disease

Sinus/hay fever

Epilepsy

Diabetes

Kidney problems

Gastric problems

Cancer/Radiation/Chemotherapy

Mental Health Condition - Depression, Anxiety or other

Artificial or prosthetic joint

Experienced excessive bleeding or bruising from dental treatment previously

Had an unfavourable reaction to LOCAL anaesthetic

Do you have or have had close contact with: HIV, Hep B, Hep C, Hep D

Acid Reflux or Eating Disorder

None of the above

Other - (Please explain...)

Confidential Patient Questionnaire

Click Submit to finish.