Online Consultation Form SimplyTeeth Essex, Online Consultation FormThank you for choosing SimplyTeethAs 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. How did you hear about us? Full Name Date of Birth Address Contact Number Email Which practice would you like to contact? IllfordHornchurchMedical QuestionnaireAre you currently pregnant? YesNoAre you currently receiving treatment from a doctor, hospital or clinic? YesNoAre you currently taking any prescribed medicines (e.g. tablets, ointments or contraceptives and hormone replacement therapy)? YesNoIf YES, please mention what medicines. If NO, please type N/A Are you carrying a medical warning card? YesNoDo you suffer from allergies to any medicine (e.g. penicillin), substances? YesNoDo you suffer from hay fever or eczema? YesNoDo you suffer from bronchitis, asthma or any other chest conditions? YesNoDo you suffer from fainting attacks, giddiness, blackouts or epilepsy? YesNoDo you suffer from heart problems, angina, blood pressure problems, or strokes? YesNoAre you diabetic (or is anyone in your family)? YesNoDo you suffer from arthritis? YesNoDo you suffer from bruising or pesistent bleeding following injury, tooth extraction? YesNoDo you suffer from any infectious diseases (including HIV and hepatitis)? YesNoHave you ever had rheumatic fever or cholera? YesNoHave you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease? YesNoHave you ever had any other serious illness? YesNoHave you ever had blood refused by the Blood Transfusion Service? YesNoHave you ever had a bad reaction to general or local anesthetic? YesNoHave you ever had joint replacement or other implant? YesNoHave you ever had treatment that required you to be in hospital? YesNoHave you ever had heart surgery? YesNoHave you ever had brain surgery? YesNoDid you receive growth hormone treatment before the mid 1980's? YesNoDo you have any close relatives (parent, sibling, grandparent) who have had creutz jakob disease? YesNoDo you regularly drink more than 14 units of alcohol per week? YesNoDo you regularly drink more than 21 units of alcohol per week? YesNoDo you smoke any tobacco products now (or did you in the past)? YesNoDo you chew tobacco, pan, use gutkha or supari or smoke shisha now (or did you in the past)? YesNoIs there any other information which your dentist might need to know about your prescribed medicines (e.g. aspirin) YesNoHave you ever thought about tooth whitening? YesNoHave you ever thought about Invisalign teeth straightening? YesNolf there is something you could change about your smile what would it be? Patient HistoryWhat is your occupation Do you have a stressful job which may lead you to grind your teeth YesNoHow 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 Next of kin Full Name Relationship to Patient Contact Number GP Details GP Name Practice Name GP Contact Number 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.This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.
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