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Patient information

We use our regular newsletter as a key communication channel to share important information about the practice, appointments and patient care. Please confirm you are happy to be kept informed.

How did you hear about the clinic? Please tick any of the following which apply:

Dentist and Doctor information

Have you been treated by your family doctor or a medical specialist for illnesses in the past year? *

Medical History

Do you have or have you had any of the following (please give details where appropriate):

Have you been told by your doctor that you need to take antibiotics before dental procedures? *
Are you allergic to any antibiotics? *
Rheumatic fever / congenital heart defect / bacterial endocarditis *
Heart Problems / angina / arrhythmia / heart attack / heart valve problems / history of cardiac surgery *
Circulatory problems / high blood pressure / stroke / transient ischaemic attack *
A history of bleeding problems or blood disorders in the family *
Chest Trouble / breathing difficulty / asthma / emphysema / bronchitis / pneumonia *
Breathing problems during sleep / sleep apnoea / snoring / periodic wakening / tiredness on waking *
Diabetes controlled by insulin (Type I) or oral medication (Type II) *
Fainting attacks / giddiness / epilepsy / fits / memory loss *
Stomach or bowel disease / gastric or duodenal ulcer / hiatus hernia / acid reflux or regurgitation *
IBS or Coeliac disease *
Renal (kidney) disease / need for dialysis *
Liver or gall bladder disease including hepatitis / cirrhosis / jaundice / gallstones *
A transplanted organ or immunosuppressive drugs *
Hormonal imbalance / endocrine / thyroid / parathyroid / pituitary / adrenal gland disease *
Skin problems / eczema / psoriasis / herpes simplex (cold sores) / delayed healing / keloid formation *
Bone or joint disorders / fractures / osteoporosis / arthritis / ankylosing spondylitis *
Headaches / migraines / jaw pain / photophobia / neck pains *
Psychiatric disorders *
Neurological disorders requiring medication / atypical facial pain / trigeminal neuralgia *
Eating disorders / anorexia / bulimia / history of vomiting *
Malignant disease (cancer) that required surgery, chemotherapy and / or radiotherapy *
Eye problems / glaucoma / loss of vision / cataract / previous eye surgery *
Autoimmune disease / rheumatoid arthritis / lupus / multiple sclerosis / fibromyalgia / Guillain-Barré *
Any artificial prosthesis (such as heart valve, pacemaker, implantable defibrillator or joint replacement) *
Sexually transmitted infection / herpes simple (HSV) / papilloma (HPV) (warts) *
Are you a carrier or any of the following blood borne diseases: HIV, Hepatitis B, Hepatitis C *
Have you been abroad or visited a country on the UK governments HCID (High Consequence Infectious Disease) list? *

Do you take or have you ever taken the following medication?

Steroid medication including tablets, creams or ointments *
Antiplatelet or anticoagulant medication *
Bisphosphonates (eg Fosamax/ Actonel) or Denosumab (Xgeva or Prolia) for osteoporosis or bone disease in the last 10 years *
Are you pregnant? *
Are you currently breastfeeding *
Do you smoke or use other tobacco products? *
Have ever smoked or used tobacco products? *
How many units of alcohol do you consume per week? *

Sleep Assessment

Certain health conditions may be related to a disturbance in your sleep. This may have an impact on the orthodontic treatment. Please answer the following sleep-related questions.

Sitting and reading *
Watching TV
 *
Sitting, inactive in a public place (e.g. a theatre or a meeting) *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon when circumstances permit *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in the traffic *

Smile Questionnaire

To be filled out by new patients.
What are your main concerns for seeking dental treatment?

Aesthetically
Dental Health
Function
Your care
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