Telephone : 01207 520 265
E: info@westlandsdentalstudio.co.uk   A: 26 Front Street, Lanchester, Durham, DH7 0ER   T: 01207520265
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Medical and Dental History

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Smile Check

Please tick the relevant boxes to help us know your current dental concerns

LET US HELP YOU TO IMPROVE YOUR MOUTH AND SMILE.....

Would you like your teeth to look whiter or brighter?
Are your teeth sensitive?
Have you any teeth you think are unsightly, mis-shapen or out of line?
Do you have any old crowns that now do not match your other teeth or have dark lines at the gums?
Do you have any old or stained fillings that show when you smile?
Do you have any silver fillings that you would like replacing with tooth coloured mercury free restorations so that they blend in better?
Do you have any missing teeth that you would like replacing to improve your smile and your bite?
Do you have an old, worn denture, or an NHS denture that looks false and feels false?
Are your teeth stained or your gums red and swollen?
Do your gums bleed when brushing?
Do you get a bad taste in your mouth or around some teeth?
Are you concerned that you may have bad breath?
Do you play contact sports without wearing a gum shield to protect your teeth, smile and your bite?

Personal Dental Assesment

Please tell us:

Your full name
Address
Postcode
Daytime number
Ext
Evening number
Mobile
Email
Date of birth
What is your occupation?
What is your doctor's name?
What is your doctor's telephone number?
Do you have any children? Yes No
Age(s) if 'yes'

We hope you will be very satisfied with the care you receive in our practice. We would like to know what made you choose us. Were any of the following reasons involved?

Convenient location
I was recommended by a friend
Convenient surgery hours
Family member already a patient here
For emergency treatment only
Referred by another dentist
Located from Yellow Pages
Located from Thomson Directory
Another reason, please specify
When did you visit your last dentist?
Have you left another practice in order to come here? Yes No
If you think it is important to explain why, please do so.

Confidential Medical History

A. ARE YOU

1. Attending or receiving any treatment from your doctor,hospital, clinic or specialist? Yes No
2. Taking any medicines or tablets prescribed by your doctor? Yes No
3. Allergic to penicillin or any other drug or substance or foods (eg latex/rubber)? Yes No
4. Pregnant or likely to be so? Yes No

B. IN THE PAST HAVE YOU

1. Ever had a heart problem, angina, high or low blood pressure, heart attack or stroke? Yes No
2. Ever had rheumatic fever? Yes No
3. Ever had jaundice, hepatitis, liver problems or kidney disease? Yes No
4. Ever had asthma, bronchitis, hayfever or any serious chest infections? Yes No
5. Ever had any blood related diseases? Yes No
6. Ever had a bad reaction to a local or general anaesthetic? Yes No
7. Ever had an operation or received hospital treatment? Yes No
8. Ever had a heart valve replaced? Yes No
9. Had a blood transfusion from the Blood Transfusion Service? Yes No
10. Had growth hormone treatment before the mid 1980's? Yes No

C. DO YOU

1. Have a pacemaker? Yes No
2. Have fainting attacks, giddiness or epilepsy? Yes No
3. Have diabetes? Yes No
4. Carry a warning card? Yes No
5. Bruise easily or have you ever bled excessively? Yes No
6. Take or have you ever taken steroids? Yes No
7. Do you smoke? Typically how many per day? Yes No
8. Have a close relative (parent, sibling, grandparent or grandchild) with Creutzfeldt Jakob disease? Yes No
9. Drink alcohol? How many units per week? (A unit is half a lager, a single measure spirit or glass of wine? Yes No
10. Suffer from headaches or migraine? Yes No
11. Suffer from Arthritis? Yes No
12. Have any infectious diseases such as HIV, CJD or Hepatitis, if so what Yes No