COVID19Screening

Patient Name: * This field is required.

First Name

Last Name

Title* This field is required.

Address* This field is required.

Street Address

Street Address Line 2

City

County

Postal Code

Country

Phone Number* This field is required.

Area Code

Phone Number

E-mail* This field is required.

How much do you smoke per day?* This field is required.

How much tobacco do you chew per day?* This field is required.

Alcohol consumption (units per week)* This field is required.

HabitsPlease select any that apply

High Sugar / Frequent sugary snacks

Lots of fizzy drinks / acidic drinks

Recreational drugs

Other

Heart ConditionsCheck the conditions that apply to you:

Rheumatic Fever

Heart Murmur

High Blood Pressure

Angina

Heart Surgery

Thrombosis

Pacemaker Fitted

Other

Blood ConditionsCheck the conditions that apply to you:

Hepatitis B

Anaemia

H.I.V.

Sickle Cell

Abnormal Blood Test

Haemophilia

Blood refused by transfusion service

Other

AllergiesCheck the allergies that apply to you:

Penecillin

Latex Allergy

Hay Fever

Medicines

Anti Tetanus Serum

Plants

Eczema

Foods

General Anaesthetic

Aspirin

Local Anaesthetic

Other

Medical WarningsCheck anything that applies to you:

Pregnant or possibly pregnant

Do Not Recline

Antibiotic Cover Required

Steroids within last 2 years

Bruising or Persistent Bleeding

Warning Card

Currently receiving medical treatment

Treatment requiring hospitalisation

Anything dentist should know

Other

Chest ConditionsCheck the conditions that apply to you:

Bronchitis

Emphysema

Cystic Fibrosis

Pneumonia

Pleurisy

Chest Surgery

Asthmatic

Other

Details of Medications If you are currently taking any medication, please list them all here. (Include name, dose and number per day) (If you aren't taking any you can skip this question)

Other ConditionsCheck the conditions that apply to you:

Liver Disease

Kidney Disease

Diabetes (patient or family)

Epilepsy

Acid Reflux or Eating Disorder

Hiatus Hernia

Bone or Joint Disease

Artificial Joint

Fainting Attacks or Blackouts

Giddiness

Past Serious or Infectious Disease

Cancer

Other

Emergency Contact Name* This field is required.

First Name

Last Name

Emergency Contact Email* This field is required.

example@example.com

Emergency Contact Phone Number* This field is required.

Area Code

Phone Number

Signature* This field is required.

Clear

Date* This field is required.

Date

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COVID19Screening