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First name:
Surname:
Phone number:
E-mail:
   
     
Medical history Yes No
Do you have any general health problems?
If so, please specify
Are you currently under a physician's care?
Reason
Name and address of Physician
Are you currently taking any drugs or medication?
If so, what?
To the best of you knowledge, are you or have you ever been
afflicted with:
Heart Ailment
Diabetes
Rheumatic Fever
Epilepsy
High blood pressure
Respiratory Disease
Hepatitis
Prolonged bleeding
Healing complication
Allergy to any drugs
Dental history
Are your teeth sensitive to:
Heat?
Cold?
Sweets?
Biting pressure?
Does food constantly get stuck between certain teeth in your mouth?
Do you get frustrated because you always have to something to be
treated or repaired when you visit a dentist?
Are you dissatisfied with your teeth in any way?
Are you dissatisfied with the way your teeth looks?
For example: color, shape, spaces, etc.
Do you have any fillings that show in your front teeth?
Do any of your filling show when you smile?
If any of your mercury amalgam fillings need replacement,
would you prefer to have a more natural, tooth-colored
restoration instead?
Have you ever had any teeth removed?
How long have these teeth been missing?
Do your gums bleed when brushing?
Do you ever avoid any part of the mouth while brushing?
Have you been instructed regarding proper home care?
Do you have an unpleasant taste or odor in your mouth?
Do you smoke?
Do you frequently snack between meals on sweets or chew gum?
How often do you brush your teeth?
How often do you use floss?
Do you want to learn to control dental disease and retain your teeth?
Has the fear of discomfort kept you from regular dental visits?
Are you deeply concerned about the finances required
to return your mouth to excellent dental health?
When was your last dental appointment?
What did you have done?
How long since your last thorough eximination with full mouth x-rays?
What prompted you to seek dental care at this time?
 
 
Kelsham Dental Care The Common Cranleigh Surrey GU6 8SN T: 01483 274552 F: 01483 272492 E: enquiries@kelshamdentalcare.com
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