Ashbourne

Your Details
     
Surname  
Forename(s)  
Title   MrMrsOther
Sex   MaleFemale
Date of Birth  
Address  
Postcode  
Home Tel No.  
Work Tel No.  
Mobile Tel No.  
Email  
     
Your Health
     
Are you receiving treatment from a doctor, hospital or clinic?   YesNo
Please provide details  
Are you taking any prescribed medicines?   YesNo
If so, what?  
Do you carry a warning card?   YesNo
Are you / could you possibly be pregnant?   YesNo
Expected Due Date?  
     
Health History    
     
Do you take steroids now or have you in the last 3 years?   YesNo
Do you have any allergies to medicines or substances?   YesNo
If so, to what?  
Do you suffer from bronchitis, asthma, eczema or hayfever?   YesNo
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy   YesNo
Do you suffer from heart problems, blood pressure, angina or stroke?   YesNo
Do you or does anyone in your family suffer from diabetes?   YesNo
Do you suffer from bruising or persistent bleeding following an injury?   YesNo
Have you ever suffered a bad reaction to a general or local anaesthetic?   YesNo
Have you ever had a joint replacement or any other implant?   YesNo
Have you ever had heart surgery or a pacemaker fitted?   YesNo
Have you ever had a stroke?   YesNo
Have you ever had jaundice, liver/kidney disease or hepatitis?   YesNo
     
Dental History    
     
When do you attend the dentist?   When in PainIrregularlyRegularly
How often do you brush your teeth?   NeverEvening OnlyMorning onlyDaily, morning and evening
Do you suffer from mouth ulcers?   YesNo
Do you suffer from cold sores?   YesNo
Do you regularly suffer from a dry mouth?   YesNo
Do you use anything to clean in-between your teeth?   YesNo
Do your gums bleed?   YesNo
Do you suffer from bad breath?   YesNo
Do you use a mouthwash?   YesNo
Are you aware if you grind your teeth?   YesNo
Do you suffer from a clicking jaw?   YesNo
Do you suffer from headaches or facial pain?   YesNo
Are you happy with the appearance of your teeth?   YesNo
How do you feel about having dental treatment?  
When did you last attend the dentist and what did you have done?  
     
Social Questions    
     
Do you smoke or use tobacco products?   YesNo
Do you drink alcohol?   YesNo
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)
  1-56-1011-15over 16
Are you happy with the appearance of your teeth?   YesNo
     
Completed By  
Date  
Any other information to add  
     
   

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Ashbourne Friends & Family