Title * -Select- Mr Mrs Ms Miss Dr Professor Other If Other please specify Patient Name * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Occupation * Address * Post Code * Email * Contact number * Emergency Contact * 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? * Yes No Chronic bronchitis? * Yes No Hay fever? * Yes No 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? How much? * Yes No If yes, how many units per week Do you smoke? How much? * Yes No If yes, how many times a day do you smoke? If yes, what do you smoke? -Select- Cigarettes Tobacco Vaping Other 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 Patient 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.