To provide the best and safest treatment, your dentist needs to know of any medical problems which may affect your treatment.
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
Select Answer No Yes
Are you taking any medicines, drugs, tablets, or injections or using any creams, ointments or inhalers?
Select Answer No Yes
Are you taking/have taken steroids in the last 2 years?
Select Answer No Yes
Are you allergic to penicillin?
Select Answer No Yes
Are you allergic to any medicines, foods or materials?
Select Answer No Yes
Are you pregnant or a nursing mother?
Select Answer No Yes
Are you HIV positive?
Select Answer No Yes
Have you had Rheumatic Fever or Chorea?
Select Answer No Yes
Have you had jaundice, liver or kidney disease or hepatitis?
Select Answer No Yes
Do you have a heart murmur, heart problem, angina or high blood pressure?
Select Answer No Yes
Have you ever had your blood refused by the Blood Transfusion Service?
Select Answer No Yes
Have you ever had a bad reaction to a local or general anaesthetic?
Select Answer No Yes
Have you had a joint replacement or implant?
Select Answer No Yes
Have you been hospitalised for any reason?
Select Answer No Yes
Do you have arthritis?
Select Answer No Yes
Do you have a pacemaker/have you had heart surgery?
Select Answer No Yes
Do you suffer from bronchitis, asthma or other chest condition?
Select Answer No Yes
Do you suffer from hay fever, eczema or any other allergy?
Select Answer No Yes
Do you have fainting attacks, giddiness, blackouts or epilepsy?
Select Answer No Yes
Do you or anyone in you family have diabetes?
Select Answer No Yes
Do you bruise easily or suffer persistent bleeding following a tooth extraction or injury?
Do you carry a warning card?
Select Answer No Yes
Are you/have you ever been a smoker?
Select Answer No Yes
On average how many units of alcohol do you drink in a week?
Are there any other aspects, concerning your health, that your dentist should know about?
Select Answer No Yes
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