PDS059 Paitent Medical Questionnaire (Portway Dental Practice)

Question Title

* First Name

Question Title

* Surname

Question Title

* Medical Questions

	Yes	No
Are you currently receiving treatment from a doctor, hospital or clinic?	Are you currently receiving treatment from a doctor, hospital or clinic? Yes	Are you currently receiving treatment from a doctor, hospital or clinic? No
Are you Currently Pregnant?	Are you Currently Pregnant? Yes	Are you Currently Pregnant? No
Are you currently taking any pills or medicines?	Are you currently taking any pills or medicines? Yes	Are you currently taking any pills or medicines? No
Are you carrying a warning card?	Are you carrying a warning card? Yes	Are you carrying a warning card? No
Do you duffer from allergies to penicillin or any medicines (e.g. antibiotics), substances (e.g. latex/rubber) or foods?	Do you duffer from allergies to penicillin or any medicines (e.g. antibiotics), substances (e.g. latex/rubber) or foods? Yes	Do you duffer from allergies to penicillin or any medicines (e.g. antibiotics), substances (e.g. latex/rubber) or foods? No
Do you suffer from asthma, hay fever or eczema?	Do you suffer from asthma, hay fever or eczema? Yes	Do you suffer from asthma, hay fever or eczema? No
Do you suffer from fainting attacks or epilepsy?	Do you suffer from fainting attacks or epilepsy? Yes	Do you suffer from fainting attacks or epilepsy? No
Do you suffer from Diabetes?	Do you suffer from Diabetes? Yes	Do you suffer from Diabetes? No
Have you ever had liver disease (e.g. jaundice, hepatitis) or Kidney disease?	Have you ever had liver disease (e.g. jaundice, hepatitis) or Kidney disease? Yes	Have you ever had liver disease (e.g. jaundice, hepatitis) or Kidney disease? No
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?	Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? Yes	Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? No
Do you suffer from Osteoporosis?	Do you suffer from Osteoporosis? Yes	Do you suffer from Osteoporosis? No
Have you ever gad any other Serious illness?	Have you ever gad any other Serious illness? Yes	Have you ever gad any other Serious illness? No
Have you ever gad a bad reaction to general or local anaesthetic?	Have you ever gad a bad reaction to general or local anaesthetic? Yes	Have you ever gad a bad reaction to general or local anaesthetic? No
Have you ever had a joint replacement or other implant?	Have you ever had a joint replacement or other implant? Yes	Have you ever had a joint replacement or other implant? No
Have you ever had a heart condition or heart surgery?	Have you ever had a heart condition or heart surgery? Yes	Have you ever had a heart condition or heart surgery? No
do you regularly drink more than 14 units of alcohol per week?	do you regularly drink more than 14 units of alcohol per week? Yes	do you regularly drink more than 14 units of alcohol per week? No
Do you use any tobacco products?	Do you use any tobacco products? Yes	Do you use any tobacco products? No
Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. Aspirin)?	Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. Aspirin)? Yes	Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. Aspirin)? No

Question Title

* If you have answer Yes for any of the questions above please state here:
(Please keep in mind your dentist will need to know of any medication your are on or any medication updates)

Question Title

* Cosmetic Questions

	Yes	No
We have recently started offering Botox and Derma Fillers at out Practice, would you like any further information about these services?	We have recently started offering Botox and Derma Fillers at out Practice, would you like any further information about these services? Yes	We have recently started offering Botox and Derma Fillers at out Practice, would you like any further information about these services? No
Are you interested in a brighter, whiter smile? would you like any further information about these services?	Are you interested in a brighter, whiter smile? would you like any further information about these services? Yes	Are you interested in a brighter, whiter smile? would you like any further information about these services? No
Are you interested in finding out how you can get straighter teeth?	Are you interested in finding out how you can get straighter teeth? Yes	Are you interested in finding out how you can get straighter teeth? No
Are there any aspects of your simile that you are not happy with?	Are there any aspects of your simile that you are not happy with? Yes	Are there any aspects of your simile that you are not happy with? No

Question Title

* If you have answer Yes for any of the questions above, and feel we may need more information, please let us know in the box below:

Question Title

* This survey was completed by:

Question Title

* Date of completion

Date

Date