Medical Questionnaire

Please complete the form below. Answers to questions marked with * are required.

Name *
Address *
Did you have rheumatic fever, have a congenital heart disease or had a heart valve replacement or a pacemaker fitted?
Do you have any heart complaints, including murmurs and chest pain (angina)?
Do you suffer from diabetes?
Do you suffer from fainting spells, dizziness, seizures or epilepsy?
Do you have asthma or chronic bronchitis?
Do you bruise easily, have abnormal bleeding times or suffer from anaemia?
Do you suffer from high blood pressure or take medication to control high blood pressure?
Do you have digestive complaints, e.g. heart burn (acid reflux) or suffer from conditions like bulimia?
Do you carry a Medic Alert warning card or bracelet?
Have you been hospitalised or undergone any surgery in the past 3 years?
Have you ever had a blood transfusion?
Have you been diagnosed with jaundice / hepatitis? If Yes, please indicate type A, B or C below.
Are you HIV positive or at risk of contracting HIV?
Have you been advised to take medication before undergoing dental procedures?
Are you suffering from any other serious illnesses?
Have you taken any of the following in the past year?
Do you have allergies or had bad reactions to any of the following?
Are you pregnant or are you breastfeeding?
Do you smoke or use any tobacco products?
If so, how much per day?
Do you consume alcohol? If so, how many units/day?
Are you using any illegal or other recreational drugs?
What are your concerns?
I am interested in having a FREE consultation for the following:
Very often clinical photography forms part of your treatment planning and progress. These images may be used for the purposes of teaching, website, articles or promotional material, in the UK and abroad. Please tick one of the boxes below to indicate consent for these images to be used: *
IGDP Limited is a private dental practice. We do not provide treatment on the NHS. *
We need at least 48 hours notification if you can't keep an appointment. Failure to do so may result in a professional fee charged at £30 / 10 minutes. IGDP Limited reserves the right not to provide treatment if you arrive late and we need to reschedule your appointment. You may still be charged for this appointment. If we run late with your appointment, we will offer to reschedule your appointment at the earliest opportunity without any cost to you. *