Medical History & Personal Dental Assessment If you are a new patient at true dentistry, may we offer you a warm welcome. We are delighted that you have selected our practice to provide your dental care. So that we can do our best for you, we would like to ask you a few questions which will take about five minutes to answer.
If you are an existing patient at true dentistry, we constantly aim to improve the service we offer you. Please could you take a few minutes to complete this personal dental assessment and bring it with you on your next visit.
Full Name
Address
Telephone Mobile
Postcode
Date of Birth
Occupation
When was your last visit?
Doctor’s Name
Doctor’s Address
We like to send out reminders to our patients before their next appointment, please tick your preferred method(s) Post
Telephone
Which of the following statements best describes your feelings about visiting the dentist? Tick the one you agree with Relaxed
A little anxious
Are there any dental procedures which have frightened you in the past, or which you are very anxious about?
Very anxious
Have you left another practice in order to come here? Yes
SMS
If you think it is important to explain why, please do so.
No
We hope you will be very satisfied with the care you receive in our practice. We would like to know what made you choose us. Were any of the following reasons involved? Convenient location
Recommended by friends/family
Convenient hours
Family member already registered
Referred by a dentist
Through Facebook, Twitter or Youtube
Through our website
Another reason Please specify
For emergency treatment only
Medical history Are you attending or receiving any treatment from your doctor, hospital, clinic or specialist?
Have you ever had a heart problem, angina, high/low blood pressure, heart attack or stroke?
Are you taking any medicines or tablets prescribed by your doctor?
Have you ever had rheumatic fever?
Are you allergic to penicillin or any other drug, substance of food?
Have you ever had jaundice, hepatitis, liver problems or kidney disease?
Are you pregnant or likely to be so?
Have you ever had a asthma, bronchitis or any serious chest infections?
Do you have a pacemaker?
Have you ever had any blood tests or blood related diseases? e.g HIV or hepatitis
Do you have fainting attacks, giddiness or epilepsy?
Have you ever had a bad reaction to a local or general anaesthetic?
Do you have diabetes?
Have you ever had an operation or received hospital treatment?
Do you carry a warning card? Have you ever had a heart valve replaced? Do you bruise easily or have you ever bled excessively?
Have you ever been diagnosed as having CJD?
Do you take or have you ever taken steroids? Do you smoke? If so, how much?
Do you drink alcohol? If so how many units? 1 unit: Per day
Approx
1/2 pint of ordinary strength beer Small glass of wine 1 single measure of spirit
Per week
You can also fill this form in online www.truedentistry.co.uk/eforms