Tooth Extraction Medical History Tooth Extraction Patient Information & Medical History Name* PrefixFirst NameLast Name Date of birth (type in or use calendar)* -Day -MonthYearDate Occupation* Address* Street Address Street Address Line 2 CityPostcode County Home phone number Please enter a valid phone number. Mobile phone number* Please enter a valid phone number. Work phone number Please enter a valid phone number. Email* example@example.com Back Next Next of kin details - emergency use only Emergency Contact Name* PrefixFirst NameLast Name Home phone number Please enter a valid phone number. Mobile phone number* Please enter a valid phone number. Work phone number Please enter a valid phone number. GP Details Dr Name* PrefixFirst NameLast Name Dr phone number* Please enter a valid phone number. Dr surgery name* Address* Street Address Street Address Line 2 CityPostcode County Nominated person who the practice can talk to on your behalf Consent Person Name PrefixFirst NameLast Name I give consent to receiving text messages YesNo Back Next 1. Do you have any problems with your heart, including high blood pressure or atrial fibrillation?* YesNo 2. Do you take any blood thinning medication?* YesNo 3. Do you have any problems with your breathing?* YesNo 4. Are you epileptic or diabetic?* YesNo Please detail below 5. Have you ever been diagnosed with "weak bones or osteoporosis?* YesNo 6. Do you take regular medication?* YesNo Please list all medications below Bring a copy of your repeat prescriptions to your appointment 7. Are you allergic to any medication (including penicillin) or to latex?* YesNo If yes, please detail below 8. Do you have any other allergies?* YesNo If yes, please detail below 9. Do you have any problems with your stomach when taking medication?* YesNo 10. Have you ever had any problems with excessive bleeding?* YesNo 11. Are you pregnant or trying to conceive?* YesNo 12. Have you ever had any form of cancer?* YesNo 13. Have you ever had any major operations or serious illness?* YesNo 14. Do you currently smoke, or given up recently?* YesNo If yes, how many did you smoke per day? 15. Is there anything else about your medical history that you think we should know?* YesNo If yes, please detail below Please bring your most recent prescription with you to your appointment. Using the following number scale, please indicate how anxious you would become in the followin situations: 1. Not Anxious • 2. Slightly Anxious • 3. Fairly Anxious • 4. Very Anxious • 5. Extremely Anxious If you were going to the dentist for treatment tomorrow, how would you feel?* Please Select 1. Not Anxious 2. Slightly Anxious 3. Fairly Anxious 4. Very Anxious 5. Extremely Anxious If you were sitting in the waiting room, waiting for treatment, how would you feel?* Please Select 1. Not Anxious 2. Slightly Anxious 3. Fairly Anxious 4. Very Anxious 5. Extremely Anxious If you were about to have a tooth drilled, how would you feel?* Please Select 1. Not Anxious 2. Slightly Anxious 3. Fairly Anxious 4. Very Anxious 5. Extremely Anxious If you were about to have your teeth scaled and polished, how would you feel?* Please Select 1. Not Anxious 2. Slightly Anxious 3. Fairly Anxious 4. Very Anxious 5. Extremely Anxious If you were about to have a local anaesthetic injection in your mouth, how would you feel?* Please Select 1. Not Anxious 2. Slightly Anxious 3. Fairly Anxious 4. Very Anxious 5. Extremely Anxious Please type your name in this box to add your signature* Date* -Day -MonthYearDate Submit Should be Empty:
