As regular patients are aware, we ask at each check-up that you complete a medical questionaire.
We have re-produced it here for you to print off and bring with you to avoid delays when you are attending the practice.

How did you hear about our practice?
Are you receiving treatment from a doctor/hospital/clinic/specialist?	Y/N
Are you pregnant?	Y/N
Are you taking any medicines from your doctor? (including oral contraceptives)	Y/N
Do you carry a medical warning card?	Y/N
Are you allergic to any medicines, foods or materials?	Y/N
Have you had rheumatic fever or chorea? (St Vitus Dance)	Y/N
Have you had jaundice, liver, kidney disease or hepatitis?	Y/N
Have you had a heart murmur/attack/problem/angina/blood pressure?	Y/N
Have you had your blood refused by the Blood Transfusion Service?	Y/N
Have you had a joint replacement?	Y/N
Do you have arthritis?	Y/N
Do you have any infectious diseases including HIV or Hepatitis?	Y/N
Do you suffer from any other serious illness?	Y/N
Do you have a pacemaker or have you had any form of heart surgery?	Y/N
Do you suffer from hay fever, eczema or any other allergy, including latex?	Y/N
Do you suffer from bronchitis, asthma or other chest condition?	Y/N
Do you have fainting attacks, giddiness, blackouts or epilepsy?	Y/N
Do you have diabetes or does anyone in your family?	Y/N
Do you bruise easily or bleed so as to cause concern after surgery?	Y/N
Have you ever had brain surgery?	Y/N
Have you ever had growth hormone treatment?	Y/N
Do you have a close relative with Creutzfeldt Jakob disease?	Y/N
Have you had a bad reaction to a local or general anaesthetic?	Y/N
Have you recently had treatment requiring hospitalisation?	Y/N
Do you have any aspects concerning health the dentist should know of?	Y/N
(Please feel free to speak to the dentists in strict confidence!).
How many units of alcohol do you drink a week (over 18\'s)	......
(A unit is a measure of spirit, a half pint of beer or a glass of wine).
Do you smoke? (Over 16\'s) If yes how many cigarettes a day?
Have you recently given up smoking?	.... ago
Do you chew tobacco, pan or supari or have you done so in the past?	Y/N
When did you last see a dentist?	......
Which dentist did you last see?
Do you suffer any discomfort from your teeth and gums when eating?	Y/N
Do your gums bleed when brushing?	Y/N
Are you happy with the appearance of your teeth and gums?	Y/N
Would you like any cosmetic treatment if available?	Y/N
Does anything concern you about your present dental health?	Y/N
Please give any other details that your dentists might need to know about such as self-prescribed medicines e.g. aspirin etc. overleaf.

What do you think of our practice?

Was the telephone answered promptly??	Y/N
Were the staff pleasant and informative??	Y/N
Do you feel that you were dealt with correctly??	Y/N
Was the waiting area comfortable??	Y/N
Was attention paid to ensuring that your treatment was as comfortable as possible??	Y/N
Was your treatment explained to you in enough detail??	Y/N
Were you given treatment options??	Y/N
Are our opening hours convenient for you??	Y/N
Are you receiving treatment from a doctor/hospital/clinic/specialist?	Y/N