Online Pre-Consultation Form

SimplyTeeth Essex, Online Consultation Form

Thank you for choosing SimplyTeeth

As part of our attempt to reduce contact time and decrease the rate of infection, we are asking all patients to prefill Covid Risk assessments and medical history forms. Please fill and sign and submit these secure forms so that they can be loaded onto your record cards before your visit.

You may experience increased waiting times as we will try and minimise the amount of patients we see, and you may be asked for deposits in advance for the increased price of PPE to be done over the phone prior to your visit.
Please help us to keep both you and Us safe.

Please answer all questions.

Full Name

Date of Birth

Address

Contact Number

Pre Visit Questions

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
YesNo

Are you/they having shortness of breath or other difficulties breathing?
YesNo

Any other flu-like symptoms, such as stomach upset, headache or tiredness?
YesNo

Have you/They experinced recent loss of taste or smell?
YesNo

Are you/they in contact with any confimed COVID-19 positive patients?(Patients who have been positive or have family members who are sick should consider postpoing dental treatments)
YesNo

Is your/their age over 60?
YesNo

Have they travelled in the past 14 days to any region affected by COVID-19?
YesNo

Do you/they have heart disease,kidney disease, lung disease, diabetes, or any other auto-immune disorders?
YesNo

Medical Questionnaire

Are you currently pregnant?
YesNo

Are you currently receiving treatment from a doctor, hospital or clinic?
YesNo

Are you currently taking any prescribed medicines (e.g. tablets, ointments or contraceptives and hormone replacement therapy)?
YesNo

If YES, please mention what medicines. If NO, please type N/A

Are you carrying a medical warning card?
YesNo

Do you suffer from allergies to any medicine (e.g. penicillin), substances?
YesNo

Do you suffer from hay fever or eczema?
YesNo

Do you suffer from bronchitis, asthma or any other chest conditions?
YesNo

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
YesNo

Do you suffer from heat problems, angina, blood pressure problems, or strokes?
YesNo

Are you diabetic (or is anyone in your family)?
YesNo

Do you suffer from arthritis?
YesNo

Do you suffer from bruising or pesistent bleeding following injury, tooth extraction?
YesNo

Do you suffer from any infectious diseases (including HIV and hepatitis)?
YesNo

Have you ever had rheumatic fever or cholera?
YesNo

Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?
YesNo

Have you ever had any other serious illness?
YesNo

Have you ever had blood refused by the Blood Transfusion Service?
YesNo

Have you ever had a bad reaction to general or local anesthetic?
YesNo

Have you ever had joint replacement or other implant?
YesNo

Have you ever had treatment that required you to be in hospital?
YesNo

Have you ever had heart surgery?
YesNo

Have you ever had brain surgery?
YesNo

Did you receive growth hormone treatment before the mid 1980's?
YesNo

Do you have any close relatives (parent, sibling, grandparent) who have had creutz jakob disease?
YesNo

Do you regularly drink more than 14 units of alcohol per week?
YesNo

Do you regularly drink more than 21 units of alcohol per week?
YesNo

Do you smoke any tobacco products now (or did you in the past)?
YesNo

Do you chew tobacco, pan, use gutkha or supari or smoke shisha now (or did you in the past)?
YesNo

Is there any other information which your dentist might need to know about your prescribed medicines (e.g. aspirin)
YesNo

Patient History

What is your occupation

Do you have a stressful job which may lead you to grind your teeth
YesNo

How Anxious are you of visiting the Dentist (Low, Medium, High)
LowMediumHigh

Dental History

When was your last dental visit?

Do you attend the dentist regularly?
YesNo

How often do you get your teeth professionally cleaned?

How many times in a day do you brush your teeth ?

What type of brush do you use (Manual or electric)?
ManualElectric

What toothpaste do you use?

Do you use interdental cleaning aids like tepes/floss?
YesNo

Do you use any mouthwashes?
YesNo

Social History

Do you drink fizzy drinks regularly
YesNo

How many cups of tea/coffee do you drink in a day

Do you put sugar in your tea or coffee
YesNo

How can we help

Are you happy with the colour of your teeth
YesNo

Have you ever thought of having your Silver/Mercury fillings replaced to white
YesNo

On a scale of 1-10 how happy are you with your smile (10 being very happy)

If you could change one thing about your smile what would it be

Have you ever thought of having your teeth straightened
YesNo

Have you ever thought of having your teeth whitened
YesNo

I confirm that all the information I have provided here is correct to the best of my knowledge and that I agree to the terms and conditions of SimplyTeeth Essex.

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