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Questionnaire
ELGIN PARK DENTAL PRACTICE
The following form must be completed prior to your visit.
Please leave blank:
Full Name:
Mobile:
Email Address:
Date of Birth:
Have you or anyone in your household had any of the following signs or symptoms in the last 14 days?
New, continuous cough?
Yes
No
Fever or high temperature?
Yes
No
Flu like symptoms? (vomiting, headache, muscle ache, fatigue):
Yes
No
Have YOU had or been in close contact with a confirmed or suspected COVID-19 infection in the last 14 days?
Yes
No
Shortness of breath?
Yes
No
Loss or change in sense of taste or smell?
Yes
No
Been told to self isolate?
Yes
No
Are you shielding or vulnerable:
Low Risk
Vulnerable
Shielding with letter
Shielding no letter
MEDICAL HISTORY
Heart Condition:
Yes
No
High Blood Pressure:
Yes
No
Asthma:
Yes
No
Chest Condition:
Yes
No
Liver Disease:
Yes
No
Diabetes:
Yes
No
Kidney Disease:
Yes
No
Epilepsy/Convulsion:
Yes
No
Cancer:
Yes
No
Are you pregnant or breastfeeding:
Yes
No
Heart Condition Details:
Blood Pressure Details:
Asthma Details:
Chest Condition Details:
Liver Disease Details:
Diabetes Details:
Kidney Disease Details:
Epilepsy Details:
Cancer Details:
Pregnancy Details:
Are you taking any medication:
Yes
No
Medication Details:
Do you have any Allergies:
Yes
No
Allergies Details:
Do you use any tobacco or electronic vaping products:
Yes
No
Number per day on average
Cigarettes:
Cigars:
Rolling tobacco:
Chewing tobacco:
Nasal snuff:
Vape:
Do you drink alcohol:
Yes
No
Regular consumption (units per week):
Please give any further information relating to your medical history that may be important:
Please confirm:
I confirm that the information provided is correct to the best of my knowledge and can be incorporated into my medical records. If completed on behalf of a family member or friend you have their permission to submit these details.
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