Leek

Your Details
     
Surname  
Forename(s)  
Title   Mr Mrs Other 
Sex   Male Female 
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?   Yes No 
Please provide details  
Are you taking any prescribed medicines?   Yes No 
If so, what?  
Do you carry a warning card?   Yes No 
Are you / could you possibly be pregnant?   Yes No 
Expected Due Date?  
     
Health History    
     
Do you take steroids now or have you in the last 3 years?   Yes No 
Do you have any allergies to medicines or substances?   Yes No 
If so, to what?  
Do you suffer from bronchitis, asthma, eczema or hayfever?   Yes No 
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy   Yes No 
Do you suffer from heart problems, blood pressure, angina or stroke?   Yes No 
Do you or does anyone in your family suffer from diabetes?   Yes No 
Do you suffer from bruising or persistent bleeding following an injury?   Yes No 
Have you ever suffered a bad reaction to a general or local anaesthetic?   Yes No 
Have you ever had a joint replacement or any other implant?   Yes No 
Have you ever had heart surgery or a pacemaker fitted?   Yes No 
Have you ever had a stroke?   Yes No 
Have you ever had jaundice, liver/kidney disease or hepatitis?   Yes No 
     
Dental History    
     
When do you attend the dentist?   When in Pain Irregularly Regularly 
How often do you brush your teeth?   Never Evening Only Morning only Daily, morning and evening 
Do you suffer from mouth ulcers?   Yes No 
Do you suffer from cold sores?   Yes No 
Do you regularly suffer from a dry mouth?   Yes No 
Do you use anything to clean in-between your teeth?   Yes No 
Do your gums bleed?   Yes No 
Do you suffer from bad breath?   Yes No 
Do you use a mouthwash?   Yes No 
Are you aware if you grind your teeth?   Yes No 
Do you suffer from a clicking jaw?   Yes No 
Do you suffer from headaches or facial pain?   Yes No 
Are you happy with the appearance of your teeth?   Yes No 
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?   Yes No 
Do you drink alcohol?   Yes No 
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)
  1-5 6-10 11-15 over 16 
Are you happy with the appearance of your teeth?   Yes No 
     
Completed By  
Date  
Any other information to add  
     
   

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Ashbourne Leek