My Dentist

Patient Registration and Health Questionnaire

Please answer all the questions as accurately as possible. If you are uncertain about any question please ask. The information collected will be retained as part of your confidential patient record.

Alternative Contact Address (if different from above)


Do iyu suffer from, or have you ever suffered from the following:

High Blood Pressure
Heart Murmur
Artificial Heart Valve
Previous Rheumatic Fever
Asthma
Shortness Of Breath
Anaemia
Blood Clots
Hepatitis / Jaundice
Kidney Problems
Blackouts / Fainting
Recreational Drugs
Joint or metal implant
Stroke
Diabetes
Previous Heart Attack
Palpitations
Chest Pains / Angina
HIV+ / AIDS
Tuberculosis
Sleep Apnoea
Bleeding or bruising
Blood Transfusion
Do You Smoke
Bronchitis
Epilepsy
Steroids
Arthritis
Do you drink alcohol
Hiatus Hernia