Aycliffe Dental Practice COVID-19 Prescreening and Medical History form

Name *

First Name Last Name

Date of Birth

Day Month Year

Sex registered at birth *

Male Female

Address *

Street Address

Street Address Line 2

Town County

Post Code Country

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

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:

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 *

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: *

Clear

Aycliffe Dental Practice

Covid-19 pre-screening

Medical History

Dental History