Patient Confidential Questionnaire Personal DetailsName(Required) DrMrMrsMsMasterMiss Title First Name Last Name Preferred Name Address(Required) Street Address City Post Code Date of Birth(Required) MM slash DD slash YYYY NHI(Required)Home PhoneWork PhoneMobileEmail(Required) Occupation(Required)School (If appropriate)Emergency Contact (Name, Relationship, Phone)(Required)Doctors Name and Practice(Required)Medical DetailsAre you receiving any medical treatment at the present time? (If yes, please give details)(Required) Yes No Are you receiving any medical treatment at the present time? Details(Required)Are you routinely taking any medication tablets, dietary supplements, capsules or drugs? If so, please name(Required) Yes No Are you routinely taking any medication tablets, dietary supplements, capsules or drugs? Names(Required)Allergy to any medication (e.g. penicillin, aspirin)?(Required) Yes No Do you have a latex allergy?(Required) Yes No Do you have an allergy to any metals?(Required) Yes No Have you ever had a bad reaction to an anaesthetic?(Required) Yes No Have you had any prosthetic surgery? (e.g. artificial joint, pacemaker, heart valve)(Required) Yes No For Females- are you pregnant?(Required) Yes No How many months have you been pregnant?(Required)Do you smoke?(Required) Yes No How many per day?(Required)Are you HIV positive or at risk of HIV exposure?(Required) Yes No Have you had the COVID vaccination?(Required) Yes Two Doses Single Dose No Have you suffered any of the following (please tick):(Required) Rheumatic fever Epilepsy Asthma Breathlessness Drug Dependence Bronchitis Migraines Heart Trouble Kidney Trouble Gastric Problems Diabetes Anemia Hepatitis (A/B/C) High Blood pressure Depressive Illness Arthritis Aids Abnormal bleeding Liver Disease Influenza Chicken pox Tuberculosis Measles/Mumps/Rubella Whooping Cough COVID 19 Dental DetailsPrevious Dentist(Required)Approximate date of Last Dental Visit:(Required) DD slash MM slash YYYY Reason for today's visit?(Required)Please tick if you have any concerns regarding the following(Required) Appearance of your teeth Sensitive teeth Decayed teeth Dry Mouth Interested in whiter teeth Sensitive/bleeding gums Food traps Mouth Ulcers/Cold sores Interested in straighter teeth Bad taste or breath Old broken/lost fillings Clicking or pain in jaw Missing teeth Loose teeth Difficulty chewing or biting Clenching or grinding Have you experienced excessive bleeding or bruising from dental treatment, cuts or scratches?(Required) Yes No Do you become anxious or uncomfortable when you are having dental treatment?(Required) Yes No If you could change anything about the appearance of your teeth, what would you like to change?Other DetailsPlease tell us how you were referred to Northcote Dental: Website Google Street Sign Yellow Pages Patient/Friend Other What is the name of the patient or friend who referred you?Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to a undergo blood test. Do you consent to a confidential blood test if this happens?(Required) Yes No I wish to discuss with the dentist at the time Terms and conditions We ask that all patients make full payment on the day of their appointment, unless prior alternative arrangements have been made. Fees and charges for treatment will always be discussed with you prior to performing services. A fee may be charged for missed appointments, appointments cancelled with less than 1 business days’ notice or late arrival to appointments. Unpaid accounts may attract interest and debt collection fees. If you are unable to make payment on the day, please advise us before the appointment begins.Do you consent to the terms and conditions?(Required) Yes Signature(Required) Δ Book your appointment today!Have a look at the wide range of dental services we offer and contact us to make an appointment today! Contact Us
