Medical History Form

Aesthetics, Dental Implant & Orthodontic Centre

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Medical Questionnaire

First Name*

Last Name

Date of Birth

Phone*

Email*

Emergency Contact

Emergency Contact's First Name

Emergency Contact's Last Name

Emergency Contact's Phone #

Relationship to patient

COVID-19 Section

It is important that you respond to these questions fully for us to be able to risk-assess you for attendance at SRDP.

IMPORTANT: Have you been in communication with someone who may have COVID-19 (coronavirus) infection or had any of the following recently?

Please Tick All That Apply

Yes, I have been in contact with someone with confirmed COVID-19 infection but I am asymptomatic

Yes, I am likely to have been in contact but it is unconfirmed and I am asymptomatic

Persistent cough

Shortness of breath or difficulty breathing

Temperature above 37.8 degrees

Any symptoms of respiratory tract illness whatsoever

Loss of taste and / or smell

Medical History

Are you currently under medical treatment?

Yes

Have you been admitted to hospital or had surgery within the last 2 years?

Yes

Are you currently taking any medications?

Yes

If Yes Please list any medications you are currently taking.

Have you ever been told by your doctor that you need to take antibiotics before dental procedures to protect your heart?

Yes

Are you pregnant?

Yes

Possibly

Are you currently breastfeeding?

Yes

Do you have any physical or mental disability that may impair your ability to understand or consent to care required

Yes

Allergies to any of the following (please tick all that apply):

I have no known allergies

Local anaesthetics

Drugs or medicines such as penicillin

General anaesthetics

Contact allergy e.g latex, metals, chemicals

Food allergy or intolerance

Other

Dental Questionnaire

How long since your last dental visit?

How would you rate your smile out of 10 (10 being perfect)?

Is there any part of your smile you would like to change?

Yes

Are you satisfied with the colour of your teeth?

Yes

Do you have gaps in your teeth that you are unhappy with?

Yes

Are you happy with the alignment of your teeth?

Yes

Are you unhappy with the appearance of any fillings or other dental work?

Yes

Are your teeth sensitive?

Yes

How many times a day do you brush your teeth?

Do you use an electric toothbrush?

Yes

Do you grind, squeeze or clench your teeth together?

Yes

Accept Data Privacy Policy of SRDP

I accept SRDP data privacy policy

HP Name

Straight Road Dental Practice

Aesthetic, Dental Implant & Orthodontic Center

118 Straight Road Lexden, Colchester CO3 9DJ Essex England

01206 769695

Opening Hours

Monday - Friday

9 am - 5:30 pm

Saturday

By Prior Appointments only

Are You A Dentist?

Refer Your Patients to SRDP

We accept referrals for Dental Implants, Fixed and Removable Orthodontics, Laser Gum Corrections, Minimally Invasive Smile Makeover, Dental Acupuncture and Dental Hypnosis at SRDP. You are welcome to refer your patients to us for the above services. Patients remain registered with the referring dentist. Thank You

Make A Referral