Boston House Dental ClinicMr Mrs Ms Miss Dr First

NameSurname

Your Address PostcodeTelephones Home: Occupation

Mobile: E-mailWork: Date of Birth

Please complete as thoroughly as possible and return at least 48 hours before attending the practice for an appointment.

Please tick as appropriate: yes no detailsHave you been in contact with someone who may have COVID-19Do you suffer from persistent coughDo you suffer from shortness of breath or difficulty breathingDo you have temperature above 37.8 degreesAny symptoms of respiratory tract illness whatsoeverLoss of taste and/or smellUnexplained tiredness or lethargyMuscular achesTravelled outside UK within past 14 Days

IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE QUESTIONS, WE WOULD STRONGLY ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH. IF YOU HAVE A DENTAL EMERGENCY PLEASE CONTACT THE PRACTICE ON INFO@BHDDC.COM SO THAT WE MAY MAKE SPECIAL ARRANGEMENTS FOR  YOUR EMERGENCY CARE.

BASED ON YOUR ACTIVITY OVER THE LAST 4 WEEKS, HOW WOULD YOU SUBJECTIVELY CLASSIFY YOUR RISK OF BEING EXPOSED TO OR INFECTED BY COVID-19?High risk - Frontline health care worker or confirmed case of infection at homeModerate risk - Key worker in contact with public but without symptoms or known exposure to an infected individualLow risk - Have been isolated / in lockdown alone or with family members with minimal social contact and no known exposure to an infected individualPreviously infected and recovered - Confirmed by hospital testing with documentation (please bring documentation with you when attending)

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GENERAL MEDICAL QUESTIONAIREPlease tick as appropriate: yes no detailsAre you having any medical treatment at the moment?Are you taking any medicines, drugs or pills?specifically: steroids (now, or in the past)? anti-coagulants? bisphosphonates?Are you pregnant?Had rheumatic fever?Had any major operations or illnesses?Had any form of hepatitis?Had positive blood test results for HIV?Reacted to local or general anaesthesia?Had a hip or other joint replacement?Do you drink alcohol? (how may units per day?)Do you smoke? (how many per day?)Do you have a pacemaker?

Do you have any allergies?

penicillinlatexiodineother

Do you have asthma?Do you have epilepsy?Do you get cold sores?Do you have diabetes? (does a family member?)Do you now, or have you ever, had problems with:Your heart? Your blood pressure?Your lungs or chest?Your liver or kidneys?Fainting?Are there any other health related issues we should know about?

for a child, the parent’s/guardian’s name(s):Your medical doctor’s name and address:How did you hear about us?

Would you like to receive notifications regarding our latest offers including orthodontics, general dentistry,hygienist services and specialist dentistry?

YES

NO

Do you have Dental Insurance cover? Cigna Denpla Bupa Aviva DPN Unum Other NoneWould you like to find out about our Practice Dental Care Plan?

Patient signature: Date: Review signature: Date:

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Clinician signature: Date: Review signature: Date:

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