Patient questionnaire

PATIENT QUESTIONNAIRE

NAME____________________________________________________MR/MRS/MISS/MS
FIRST MIDDLE SURNAME
ADDRESS______________________________________________________________________
_______________________________________________________________________________
PHONE HM___________________WK__________________CELL_______________________
EMAIL________________________________________________________________________
OCCUPATION______________________________________________________
DATE OF BIRTH____________________
NAME/SOURCE OF REFERRAL_______________________________________
NAME OF MEDICAL PRACTITIONER__________________________________
In order to provide the best and safest dental treatment, your dentist needs to know of any medical
problems which may affect your treatment.
ARE YOU RECEIVING ANY MEDICAL TREATMENT AT THE PRESENT TIME? Yes / No
ARE YOU TAKING ANY TABLETS, CAPSULES, MEDICINES OR DRUGS? Yes / No IF YES, PLEASE LIST:________________________________________________________ ARE YOU WEARING AN ARTIFICIAL OR PROSTHETIC JOINT? Yes / No
EG HIP, HEART VALVE ETC
DO YOU NORMALLY HAVE A L. A. (INJECTION) FOR TREATMENT? Yes / No
HAVE YOU EVER HAD A REACTION TO AN ANAESTHETIC? Yes / No
IF SO TO A LOCAL OR GENERAL ANAESTHETIC? ________________________________
WOMEN: ARE YOU PREGNANT NOW? Yes / No MONTHS____________________________
WHEN WAS YOUR LAST ROUTINE DENTAL EXAMINATION? ______________________
DO YOUR GUMS BLEED? Yes
ARE THERE ANY OTHER ASPECTS CONCERNING YOUR HEALTH THAT YOU THINK YOUR DENTIST SHOULD KNOW ABOUT? Yes - No SIGNED BY: PATIENT/PARENT/GUARDIAN______________________________________ PERSON RESPONSIBLE FOR ACCOUNT IF UNDER 18 YEARS______________________ DATE____________________________________ • PLEASE NOTE THAT PAYMENT IS EXPECTED AT THE END OF EACH APPOINTMENT. ANY
RECOVERING COSTS INCURRED WILL BE YOUR RESPONSIBILITY.
• PLEASE NOTE THAT A FEE MAY BE CHARGED FOR MISSED APPOINTMENT OR LATE
CANCELLATION
MEDICAL HISTORY
Please tick where appropriate
HEART CONDITONS
CHEST CONDITIONS
O Rheumatic Fever
O Bronchitis
O High Blood Pressure
O Emphysema
O Heart Surgery
O Pneumonia
O Pacemaker Fitted
O Chest Surgery
O Heart Murmur
O Thrombosis
O Cystic Fibrosis
O Pleurisy
………………………………………….
……….
BLOOD CONDITIONS
ALLERGY CONDITIONS
O Bleeding
O Penicillin
O Hepatitis B
O Hay Fever
O Anti-Tetanus Serum
O Anaemia
O Blood Test
O Aspirin
O Sickle Cell
O Asthmatic
O Haemophilia
O Latex Allergy
………………………………………….
………………………………………….
OTHER CONDITIONS
MEDICAL HISTORY UPDATE
O Serious childhood illness
DATE INITIALS
O Diabetes
1. ……………………………….
O Liver disease
2. ……………………………….
O Kidney disease
3. ……………………………….
O Epilepsy
4. ……………………………….
5. ……………………………….
O G. A. Experience
6. ……………………………….
O Hiatus hernia
7. ……………………………….
8. ……………………………….
……………………………………….
9. ……………………………….
10. ……………………………….

Source: http://www.woodward-dental.co.nz/upload/modules/file_storage/New%20Patient%20Form.pdf