Medical Questionnaire - Islington Green Dental Practice

Step 1 of 6

16%

Name(Required)

First Last

Date of Birth(Required)

Day

Month

Year

Address(Required)

Street Address Address Line 2 Town Post Code Country

Email(Required)

Mobile Phone(Required)

Home Phone

Did you have rheumatic fever, have a congenital heart disease or had a heart valve replacement or a pacemaker fitted?(Required)

Yes

Do you have any heart complaints, including murmurs and chest pain (angina)?(Required)

Yes

Do you suffer from diabetes?(Required)

Yes

If Yes, please indicate TYPE1 (insulin controlled) or TYPE 2 (diet controlled) below.(Required)

Type 1 (insulin controlled)

Type 2 (diet controlled)

Do you suffer from fainting spells, dizziness, seizures or epilepsy?(Required)

Yes

Do you have asthma or chronic bronchitis?(Required)

Yes

Do you bruise easily, have abnormal bleeding times or suffer from anemia?(Required)

Yes

Do you suffer from high blood pressure or take medication to control high blood pressure?(Required)

Yes

Do you have digestive complaints, e.g. heart burn (acid reflux) or suffer from conditions like bulimia?(Required)

Yes

Do you carry a Medic Alert warning card or bracelet?(Required)

Yes

Have you been hospitalised or undergone any surgery in the past 3 years?(Required)

Yes

Have you ever had a blood transfusion?(Required)

Yes

Have you been diagnosed with jaundice / hepatitis?(Required)

Yes

If Yes, please indicate type A, B or C below.(Required)

Are you HIV positive or at risk of contracting HIV?(Required)

Yes

Have you been advised to take medication before undergoing dental procedures?(Required)

Yes

Are you suffering from any other serious illnesses?(Required)

Yes

Have you taken any of the following in the past year?(Required)

Antibiotics / sulfa drugs

Anticoagulants / High blood pressure medication

Antidepressants

Insulin or related drugs

Drugs for heart conditions

None

Do you have allergies or had bad reactions to any of the following?(Required)

Local anaesthetic

Penicillin or other antibiotics

Sulfa drugs

Aspirin

Codeine

Iodine

Latex / rubber

None of the above

Other

Do you smoke or use any tobacco products?(Required)

Yes

If so, how much per day?(Required)

1-10

10-20

20+

Please list ALL the medicines you take, including self-prescribed preparations. Also provide the dosage for your medication.

Are you pregnant or are you breastfeeding?(Required)

Yes

Do you consume alcohol? If so, how many units/day?(Required)

< 1

1 – 2

3 – 5

> 6

Are you using any illegal or other recreational drugs?(Required)

Yes

If Yes, please provide more details in the space below.(Required)

Name of your GP(Required)

GP's practice name and address, including postcode(Required)

GP's telephone number(Required)

How long ago did you last visit a dentist?(Required)

Less than a month

1 – 6 months

7 – 12 months

12 months +

Can’t remember

How long has it been since you visited a dental hygienist?(Required)

Less than a month

1 – 6 months

7 – 12 months

12 months +

Can’t remember

How did you find out about us?(Required)

What is your main concern?(Required)

I am not happy with my smile.

I am concerned about the effect of my teeth on my personal life and career.

I have bad breath.

I have bleeding gums.

I have sensitive teeth.

I have stained teeth.

I have crooked teeth I want treated.

I can’t clean my teeth properly.

I have loose teeth or have missing teeth.

I have broken fillings / teeth / crowns / veneers.

I can’t chew properly.

I do not like some of my old fillings / crowns / caps.

I am clenching / grinding my teeth.

My jaw hurts / my wisdom teeth are hurting me.

I am concerned about the effect of the condition of my teeth on my general health.

I am fearful of having dental treatment.

I am concerned over the potential cost of my treatment.

I have other concerns I will discuss with my dentist / hygienist.

For any other concerns, please specify.

I am interested in having a FREE consultation for the following:

Options available to straighten my teeth.

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 select one of the boxes below to indicate consent for these images to be used:(Required)

I consent to all images being used anonymously under the Data Protection Act 2018.

I consent to all images being used anonymously, apart from images of my face, under the Data Protection Act 2018.

I do not consent to any images being used.

IGDP Limited is a private dental practice. We do not provide treatment on the NHS.(Required)

I understand I have to pay for my treatment.

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.(Required)

I have read, understood and agree to the terms of my bookings.

Signature

Name

This field is for validation purposes and should be left unchanged.

Monday	8:00 AM - 15:00 PM
Tuesday	8:00 AM - 15:00 PM
Wednesday	8:00 AM - 15:00 PM
Thursday	8:00 AM - 15:00 PM
Friday	8:00 AM - 15:00 PM
Saturday	8:00 AM - 13:00 PM