This provides the dentist with important information required for your dental treatment and oral health care.
Date of Birth:
Next of Kin / Emergency Contact:
1.
Are you receiving any medical treatment at the present time?
YesNo
2.
Have you been a patient in hospital during the past two years?
3.
Have you taken any tablets, or drugs during the past two years?
4.
Have you experienced any allergies or unusual effects from any tablets, drugs, injections or anaesthetic?
5.
Are you, or have you been, under the care of a doctor for anything major during the past two years?
6.
Have you ever had any of the following? If so, please tick as appropriate
Rheumatic FeverEpilepsyDrug DependenceHeart TroubleAnaemiaSevere HeadachesHigh Blood PressureDiabetesDepressive IllnessAsthmaKidney TroubleCold SoresArthritisGastric ProblemsHepatitis - Specify type; A, B, CBronchitis or Chest Problems
7.
Have you had any prosthetic surgery? (e.g. Heart Valve or Hip Replacement)
8.
Females only; are you pregnant?
9.
Do you Brush Twice Daily?
10.
Do you Floss Every Day?
11.
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
12.
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during your treatment, our practice requires both patient and staff members to undertake a confidential blood test.
Do you agree to a blood test?
YesNoWish to discuss with the dentist
13.
Ethnic Group:
N.Z EuropeanMaoriSamoanCook IslandTonganChineseIndianOther
Signature of Parent/Guardian: (if patient is a minor)
Date:
