Online Pre-Consultation Form for New Patients 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. How did you hear about us? Full Name Date of Birth Address Contact Number Email 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 heart 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. This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.