New Patient Registration Form In order for us to provide you with the best care, please complete the following confidential questions: (*-compulsory fields) Personal Assessment and Medical History NHS Number*: Title*: Name*: Surname*: DOB*:(dd/mm/yyyy) Address*: City*: Postcode*: Email*: Tel:(incl.country code) mob*: How did you hear about us: Date of last detnal examination: (dd/mm/yyyy) Date of last hygiene appointment: (dd/mm/yyyy) General Practitioner name: General Practitioner address and phone number: The Health Questions below are important to your dentist. Do not worry about questions you cannot answer, but feel free to discuss them further with your dentist. 1. Received treatment from doctor, hospital or clinic?: YESNOnot applicable If yes please give details in space on the right. 2. Taking any prescribed medicines?: YESNOnot applicable If yes please give details in space on the right. 3. Carrying a medical warning card?: YESNOnot applicable If yes please give details in space on the right. 4. Are you pregnant/expecting a baby?: YESNOnot applicable If yes please give details in space on the right. 5. Allergies to any medicines, substances or food?: YESNOnot applicable If yes please give details in space on the right. 6. Bronchitis, asthma or other chest conditions?: YESNOnot applicable If yes please give details in space on the right. 7. Fainting attacks, giddiness, blackouts, epilepsy?: YESNOnot applicable If yes please give details in space on the right. 8. Heart problems, angina, blood pressure problem or stroke?: YESNOnot applicable If yes please give details in space on the right. 9. Diabetes (or does anybodyin your family)?: YESNOnot applicable If yes please give details in space on the right. 10. Bone or joint disease?: YESNOnot applicable If yes please give details in space on the right. 11. Bruising or persistent bleeding following injury, tooth extraction or surgery?: YESNOnot applicable If yes please give details in space on the right. 12. Liver disease or kidney disease?: YESNOnot applicable If yes please give details in space on the right. 13. Any other serious illness or infectious disease?: YESNOnot applicable If yes please give details in space on the right. 14. A bad reaction to general or local anaesthetic?: YESNOnot applicable If yes please give details in space on the right. 15. Ever had a serious illness or operation that required you to be in hospital?: YESNOnot applicable If yes please give details in space on the right. 16. Heart surgery?: YESNOnot applicable If yes please give details in space on the right. 17. How many units of alcohol do you drink per week?: None 1-3 4-6 7 or more You can add comments in the field on right. 18. Do you smoke tobacco products now (in the past)?: YESNOnot applicable If yes please give details in space on the right. 19. Do you chew tobacco, pan, use guthka, or supari now (or in the past)?: YESNOnot applicable If yes please give details in space on the right.
