Title * -select- Mr Mrs Ms Miss Dr Professor Other If Other please specify Patient name * DOB * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Occupation * Address * Post Code * Email * Contact number * Emergency Contact * Do you have any underlying health issues such as heart, lung or kidney disease, diabetes or auto-immune disorders? * Yes No Are you or anyone in your household currently ‘’shielding’’? * Yes No Risk of current COVID-19 infection – in the last 14 days Have you felt feverish or had a temperature of 37.8°C or higher? * Yes No Do you have a new, persistent cough? * Yes No Are you having shortness of breath or any difficulties breathing? * Yes No Any flu-like symptoms such as stomach upset, fatigue or unusual tiredness, muscle pains or a persistent headache? * Yes No Have you experienced recent loss of taste, smell or appetite? * Yes No Has anyone you live or work with had any of the symptoms above? * Yes No If you or anyone in your household has tested positive for coronavirus, are you still in the self/household isolation period? * Yes No Medical History Questionnaire Do you or have you suffered from any of the following: Any heart complaint, heart surgery or stroke? * Yes No High blood pressure? * Yes No Excessive bleeding? * Yes No Asthma? Chronic bronchitis? * Yes No Hay fever? Eczema? * Yes No Diabetes? * Yes No Liver disease? Hepatitis? * Yes No Have you ever needed to see a neurologist or had any form of brain surgery in the past? * Yes No Any other serious illness? * Yes No Any other medical condition? * Yes No Allergies: Are you allergic to any medicine, tablets, latex or any other substances? * Yes No Have you been infected with HIV or Viral Hepatitis (Hepatitis B or C)? You may tick box or tell the Endodontist * Yes No Do you drink alcohol? * Yes No If yes, how many units per week Do you smoke? * Yes No What do you smoke? -select- Cigarettes Tobacco Vaping Other How many times a day do you smoke? Do you have private dental insurance? * Yes No Consent for clinical images: I authorise images of my tooth/teeth to be recorded which will allow clinical information to be passed to my dentist to facilitate further treatment. These will be kept securely in my confidential clinical records. * Yes No If ‘YES’ to any questions please supply details in the box below Please list any medication that you may be taking in the box below Signature Signer Name * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.