Parkside Dental Patient Health Questionnaire

CONFIDENTIAL PATIENT HEALTH QUESTIONNAIRE

This form provides the dentist with information required for your dental treatment and oral health care. In order to provide the best and safest dental treatment, your dentist needs to know any medical problems, which may affect your treatment. Please only complete this form if you are an existing patient with Parkside Dental needing to update your details, or if you have an appointment booked with us.
1. Your Details

Please complete the section below.
Your Title:
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Your Gender*

MaleFemaleNot Specified
NHI Number (if known)
Address*

Street Address

Street Address Line 2

CityProvince

Post Code
Occupation/School
Mobile Number*
Home/Work Number
E-mail*
How did you hear of this practice?
2. Medical History

Please complete the section below.
Have you been a patient in hospital during the past two years?*

YesNo
Please provide details:
Have you had any prosthetic surgery? (e.g. Heart valve or hip/knee replacement)?*

YesNo
Please provide details:
Are you currently receiving active treatment from a doctor or hospital?*

YesNo
Please provide details:
Are you currently taking any tablets, medicines, pills or drugs? *

YesNo
Please list:
Have you experienced any allergies or unusual effects from any tablets, drugs, injections or local anesthetic, in particular penicillin or materials such as latex?*

YesNo
Please list:
Have you experienced excessive bleeding/bruising from dental treatment?*

YesNo
Please provide details
Have you ever had any of the following? (If yes, please TICK all as appropriate)

Rheumatic FeverHigh Blood PressureHeart SurgeryPacemakerHeart MurmurAnginaThrombosisHepatitis AHepatitis BHepatitis CGastric problemsAnaemiaSinusitisHay feverBronchitis (Chest Problems)AsthmaJaundice / Liver diseaseDiabetesFainting Attacks/ BlackoutsDepressive illnessSevere headachesKidney troubleEpilepsyArthritisCold soresTaken Bone Medication e.g. FosamaxDrug dependenceHIV PositiveHead/Neck radiotherapy
Have you had any other heart conditions?*

YesNo
If Yes, please give details
Have you had cancer?*

YesNo
If Yes, please give details
Are you pregnant?*

YesNo
If Yes, how many weeks:
Do you smoke or vape?*

YesNo
Are there any other health matters that your dentist should know about?*

YesNo
If Yes, please give details
Emergency Contact *

First NameLast Name
Relationship*
Phone number*
Medical Doctor (GP) / Medical Practice*
Pharmacy/Chemist
In the event of an emergency, do you require assistance to evacuate the building?*

YesNo
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to undertake a confidential blood test.
Do agree to a blood test?*

YesNoI wish to discuss this with the dentist
3. Dental History

Please complete the section below.
Date of last dental visit?
Last Dental Practice / Dentist
How often do you brush your teeth?
How often do you floss your teeth?
4. Consent
As we do not provide payment plans, we require payment on the day of treatment. All costs incurred to recover debts will fall under the liability of the patient.
This form was completed by? (please select one)*

MyselfParentGuardian
Your Signature*

Clear
Date*

DayMonthYear
Should be Empty:

CONFIDENTIAL PATIENT HEALTH QUESTIONNAIRE

1. Your Details

2. Medical History

3. Dental History

4. Consent