Your Details
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Surname
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Forename(s)
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Title
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MrMrsOther
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Sex
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MaleFemale
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Date of Birth
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Address
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Postcode
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Home Tel No.
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Work Tel No.
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Mobile Tel No.
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Email
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Your Health
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Are you receiving treatment from a doctor, hospital or clinic?
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YesNo
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Please provide details
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Are you taking any prescribed medicines?
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YesNo
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If so, what?
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Do you carry a warning card?
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YesNo
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Are you / could you possibly be pregnant?
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YesNo
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Expected Due Date?
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Health History
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Have you been diagnosed with Coronavirus?
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YesNo
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Have you been in contact with someone with confirmed Coronavirus?
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YesNo
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Are you self isolating?
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YesNo
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If so why?
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Do you have or have had :
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A persistent (new) dry cough in the last 14 days ?
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YesNo
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Do you have loss of taste or smell?
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YesNo
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Are you a patient in a vulnerable group or at increased risk of Covid -19?
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YesNo
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Do you or have you had a temperature greater than 37.8degrees c in the last 14 days?
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YesNo
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Have you had a rash in the last 14 days?
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YesNo
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Have you had diarrhoea in last 14 days?
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YesNo
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Have you suffered with vomiting in last 14days?
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YesNo
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Have you had a eye infection in last 14 days?
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YesNo
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Have you been abroad in the last 14 days?
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YesNo
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Do you take steroids now or have you in the last 3 years?
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YesNo
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Do you have any allergies to medicines or substances?
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YesNo
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If so, to what?
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Do you suffer from bronchitis, asthma, eczema or hayfever?
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YesNo
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Do you suffer from fainting attacks, giddiness, blackouts or epilepsy
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YesNo
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Do you suffer from heart problems, blood pressure, angina or stroke?
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YesNo
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Do you or does anyone in your family suffer from diabetes?
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YesNo
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Do you suffer from bruising or persistent bleeding following an injury?
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YesNo
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Have you ever suffered a bad reaction to a general or local anaesthetic?
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YesNo
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Have you ever had a joint replacement or any other implant?
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YesNo
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Have you ever had heart surgery or a pacemaker fitted?
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YesNo
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Have you ever had a stroke?
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YesNo
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Have you ever had jaundice, liver/kidney disease or hepatitis?
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YesNo
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Dental History
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When do you attend the dentist?
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When in PainIrregularlyRegularly
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How often do you brush your teeth?
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NeverEvening OnlyMorning onlyDaily, morning and evening
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Do you suffer from mouth ulcers?
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YesNo
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Do you suffer from cold sores?
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YesNo
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Do you regularly suffer from a dry mouth?
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YesNo
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Do you use anything to clean in-between your teeth?
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YesNo
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Do your gums bleed?
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YesNo
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Do you suffer from bad breath?
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YesNo
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Do you use a mouthwash?
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YesNo
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Are you aware if you grind your teeth?
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YesNo
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Do you suffer from a clicking jaw?
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YesNo
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Do you suffer from headaches or facial pain?
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YesNo
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Are you happy with the appearance of your teeth?
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YesNo
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How do you feel about having dental treatment?
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When did you last attend the dentist and what did you have done?
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Social Questions
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Do you smoke or use tobacco products?
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YesNo
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Do you drink alcohol?
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YesNo
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How many units of alcohol do you drink in a week?
(a unit is half a pint of beer or a single shot of spirits or a small glass of wine)
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1-56-1011-15over 16
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Are you happy with the appearance of your teeth?
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YesNo
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Completed By
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Date
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Any other information to add
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