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

     

     

     

     

     

    Have you been diagnosed with Coronavirus?

     

    YesNo

    Have you been in contact with someone with confirmed Coronavirus?

     

    YesNo

    Are you self isolating?

     

    YesNo

    If so why?

     

    Do you have or have had :

     

     

    A persistent (new) dry cough in the last 14 days ?

     

    YesNo

    Do you have loss of taste or smell?

     

    YesNo

    Are you a patient in a vulnerable group or at increased risk of Covid -19?

     

    YesNo

    Do you or have you had a temperature greater than 37.8degrees c in the last 14 days?

     

    YesNo

    Have you had a rash in the last 14 days?

     

    YesNo

    Have you had diarrhoea in last 14 days?

     

    YesNo

    Have you suffered with vomiting in last 14days?

     

    YesNo

    Have you had a eye infection in last 14 days?

     

    YesNo

    Have you been abroad in the last 14 days?

     

    YesNo

    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