Name
Title
Address
Male / female MaleFemale
Date of Birth
Telephone
Email
Occupation
GP Details
PPS No.:
PPS Approved (office use)
How did you hear of this Practice?
If referred by whom?
Dental History
Are you concerned about or experiencing any of the following Dental Problems? Bleeding GumsYour SmileClicking/pain in jawMissing teethHead/Neck AcheCrooked TeethGaps between teethCrowns, bridges or denturesSilver fillingsRoughness of existing fillingsDiscoloured fillingsFood trapping between teethStaining of teethSensitivity to hot and coldTeeth cleaning techniquesTeeth Whitening
What is the main purpose of your visit today
How long has it been since your last dental visit?
Does Dental Treatment Make you nervous?
NoSlightlyModeratelyExtremely
Is Six Month Smiles, Clear Adult Braces, right for you? The best way to find the answer to that questions is to ask a member of staff.
1. Are you currently receiving treatment from a doctor, hospital or clinic? YesNo
2. Have you ever had treatment that required a stay in the hospital? YesNo
3. If so, did it involve surgery? YesNo
4. Do you carry a medical warning card/bracelet? YesNo
5. Are you taking any form of prescribed medication? YesNo
6. Do you suffer from any allergies to medicines, substances or food? YesNo
7. Are you taking Bisphosphates? (arthritis medication) YesNo
8. Have you ever had Liver Disease (e.g. Jaundice/Hepatitis) or Kidney Disease? YesNoYesNo
9. Have you ever had a Heart Murmur, Stroke, Angina, Blood Pressure? YesNo
10. Have you ever had any Heart Surgery? YesNo
11. Have you ever had a bad reaction to general or local anaesthetic? YesNo
12. Have you ever had a joint replacement or any other implant? YesNo
13. Are you pregnant or had a baby in the last year? YesNo
14. Do you suffer from bronchitis, asthma or other chest conditions? YesNo
15. Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? YesNo
16. Are you diabetic (or anyone in your family)? YesNo
17. Do you suffer from bruising or persistent bleeding following injury,Tooth extraction or surgery? YesNo
18. Do you suffer from any infectious disease (including HIV and hepatitis)? YesNo
19. Do you suffer from Rheumatism or Arthritis? YesNo
20. Is there any other information your Dentist may need to know about you? YesNo
IF YOU ANSERWED YES TO ANY OF THE ABOVE PLEASE GIVE DETAILS:
Please be advised that there will be a €50 fee to those who either do not show up for their appointment or do not cancel within 24 hours.
(Parent / Guardian)
Date
