Language
English (UK)
Aycliffe Dental Practice
COVID-19 pre-screening & Medical History Form
Name
*
First Name
Last Name
Date of Birth
/
Day
/
Month
Year
Date Picker Icon
Sex registered at birth
*
Male
Female
Address
*
Street Address
Street Address Line 2
Town
County
Post Code
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
example@example.com
Occupation
Details of person to contact in an emergency
*
Emergency Contact Name
Contacts Phone Number
*
-
Area Code
Phone Number
Doctor's Name
*
Doctor's Address
*
Doctor's Phone Number
*
-
Area Code
Phone Number
Covid-19 pre-screening
These questions must be answered honestly. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:
*
YES
NO
Do you have a fever or above normal temperature?
Have you experienced shortness of breathe or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you travelled outside the United Kingdom by air or cruise ship in the past 14 days?
Have you travelled within the United Kingdom by air, bus or train within the past 14 days?
Do you have a weakened immune system?
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?
Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your doctor if not sure. Also, answer YES if unsure.
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?
Do you have diabetes?
If so, do you have to take insulin injections?
Do you have asthma or COPD?
Explain any YES answers in the box below:
Medical History
1. Are you receiving any medical treatment
*
Yes
No
If yes provide details
2. Have you been a patient in hospital or under care of a doctor during the past two years
*
Yes
No
If yes provide reason
3. Have you taken any medicine tablets, drugs or injections or using creams, ointments or inhalers
*
Yes
No
If yes provide details
4. Have you experienced any allergies or unusual effects from any materials, medications or anaesthetic?
*
Yes
No
If yes provide details
5. List any self prescribed medicines, e.g. Aspirin
6. Have you had any of the following?
Check as
appropriate
Rheumatic Fever
Heart trouble
High blood pressure
Asthma
Arthritis
Epilepsy
Anaemia
Diabetes
Kidney trouble
Gastric problems
Cold sores
Depressive illness
Drug dependence
Hepatitis A, B, C, D
Bronchitis or Chest Problems
7. Have you had any prosthetic surgery? (e.g. heart valve, hip replacement, pacemaker)
*
Yes
No
If yes provide details
8. Are you pregnant or breastfeeding?
Yes
No
9. Are you HIV positive?
*
Yes
No
10. Are you at risk to HIV exposure?
*
Yes
No
11. Do you have any hidden disabilities?
*
Yes
No
If yes provide details
12. Do you smoke or chew tobacco?
*
Yes
No
If yes how many per day
13. Do you snore or suffer from sleep apnoea?
*
Yes
No
14. Do you drink alcohol?
*
Yes
No
If yes how many units per week
15. Approximate Weight
*
16. Approximate height
*
Dental History
1. Approximate date of last dental visit
2. Do you have dental pain or a dental problem at present
*
Yes
No
If yes provide details
3. Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
*
Yes
No
4. Is there any other condition your dentist needs to be aware of that may affect you dental treatment
*
Yes
No
If yes provide details
Signature: By signing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge and you consent to Aycliffe Dentistry using your information for the purposes of providing you with dental treatment:
*
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