Koray Feran - Patient Questionnaire

New Patient Questionnaire

Patient Questionnaire: Please complete as fully as possible.

* = Required Fields
  1. * Title: * Date of birth:
  2. * First Name(s) * Surname:
    Please address me as:  
  3. * Full address including postal code
  4. * Contact numbers (Please tick box(es) for preferred contact method)  
 
Home:  
Work:
Fax:     
Mobile:
Email(Home):  
Email(Work):  
 
5. * Occupation:
     
6. * Name of person who recommended you to this practice
     
7. * Name and address of person responsible for accounts
if different from above:
     
8. * Are you covered by a medical or dental insurance policy?
If so which one?
Yes NO
     
9. * Name, address and telephone number of
General Medical Practitioner:
     
10. * Name, address and telephone number of
regular General Dental Practitioner:
     
   
 

Please complete the medical history questionnaire below.

Please remember all information is confidential.

Confidential Medical History Questionnaire: Please complete as fully as possible

Yes

No

1. Have you been seen by your family doctor or a medical specialist in the past year?
2. * Have you been hospitalised for serious illness or an operation in the past 3 years?
If yes to 1. or 2. , please give details…
3. Do you have a registered disability? If yes please give details:
4. Have you ever been told by your doctor that you need to take antibiotics before dental procedures to protect your heart?                                        
5. Do you carry a Medic Alert card or bracelet?
6. Have you ever had a blood transfusion?

 Do you have, or have you ever had, any of the following?

Please select those applicable. If the answer is yes to any of the questions below,
please provide details in the text box which will appear if the "Yes" option is clicked

Yes

No

7. Rheumatic fever / congenital heart defect / bacterial endocarditis
8. Heart trouble / angina / high blood pressure / arrhythmia
9. Jaundice / hepatitis or other liver or gall bladder disease.
10. Chest trouble / breathing difficulty /asthma/emphysema / bronchitis.
11. A history of bleeding problems or blood disorders in the family
12. Diabetes (Controlled by insulin (Type I) or oral medication (Type II)?)
13. Allergy or adverse reactions to any drugs (e.g. penicillin)?
14. Allergy or adverse reaction to local or general anaesthetics.
15. Fainting attacks / giddiness / epilepsy / fits / memory loss
16. Stomach or bowel trouble / hiatus hernia / acid reflux or regurgitation
17. Eczema or contact allergy (e.g. to latex, or certain metals)
18. Bone or joint disorders (e.g. osteoporosis, arthritis, Paget’s disease)
19. Psychiatric or neurological disorders requiring medication
20. Are you a smoker or have you been a smoker within the last 5 years?
21. How much do (did) you smoke per day?
22. How many units of alcohol do you drink per week?
23. Have you, in the last two years, received any steroid medication?
24. Do you take anticoagulant (blood thinning) medication?
25. Do you take bisphosphonate medication (such as Fosamax or Actonel)?
26. Do you have any artificial prostheses (such as a heart valve or joint replacements)?
27. Do you have a pacemaker for your heart?
28. Are you pregnant?

         Possibly


29 Are you HIV positive or Hepatitis B or C positive?
 
30. Do you have a close family member with inherited variant Creutzfeldt-Jakob disease?
31. Have you been treated with growth hormone before the mid 80’s or received a
dura mater graft following neurosurgery?
32. Please list all the medicines (prescribed, over the counter or self medication) you take
on a regular basis (including contraceptive pills, homeopathic and herbal remedies,
ointments, recreational drugs). If possible, please include dosages and frequency.
 
Medication Name
Dosage (amount and frequency) Taken since
33.

Please add anything else that you feel may be of medical importance.

   
 
       

Confidential Dental History Questionnaire: Please complete as fully as possible.

 

   On a scale of 1 (poor) to 10 (perfect) how would you rate your current dental condition?

Appearance 1 2 3 4 5 6 7 8 9 10
Health 1 2 3 4 5 6 7 8 9 10
Comfort 1 2 3 4 5 6 7 8 9 10
Function 1 2 3 4 5 6 7 8 9 10
 

   Which of the following concern you?

Unattractive appearance
Bad breath
Bleeding gums
Sensitive teeth
The need for frequent replacement of dental work due to new decay
The colour of your teeth
Crooked teeth
Mobile, wobbly or drifting teeth
Tooth loss
Gaps between your teeth which look unattractive or trap food
Uncomfortable or mobile dentures
Unattractive previous dental work such as silver fillings or dark crown edges
Difficulty with cleaning between and around your teeth
Fear or apprehension of dental procedures
Difficulty in eating comfortably or bringing your teeth together due to jaw joint or muscle pain
The effect of your dental condition on your general health
The effect of your dental condition on your personal life
The effect of your dental condition on your work life and career
 
 
* Please indicate if you have any other issues you would like addressed?
 

Wishes, expectations and constraints

Very often patients do not feel that they have been able to ask all of the questions they wanted to ask or convey all of the information they wished to convey when they attend for their consultation. Please take the time to complete the following section as thoroughly as possible in your own time so that I can be well prepared when we meet.
   
  * 1.If you had a magic wand, what would you like to achieve as far as your dental condition is concerned? (Please include as much detail as possible, whether it is about your appearance, your comfort, your feelings, other people's impression of you or indeed anything that matters)
 
   
  2. What has prompted you to come to my practice?
 
   
  3. What has prompted you to come now? Has there been any event, or trigger that has prompted you to seek my advice at this time?
 
   
  4. What are the priorities for you now?
 
   
  5. When would you like this addressed and completed? Is there a deadline?
 
   
  6. Have you considered having this work done in the past and if so, why did you postpone?
 
   
  7. Do you have time constraints that make it difficult for you to have treatment during normal working hours or attending for long appointments or frequent appointments?
 
   
 

8. Has the potential financial investment involved ever influenced you seeking ideal treatment?

   
 
Yes No Partially
   
 

9. If so, would you be interested in taking advantage of a payment plan or staging treatment over a period of time?

   
 
Yes No May be
 

* Please note that most treatment carried out at my practice is photographically and occasionally video documented as part of your clinical record. These images may be used anonymously for the purposes of teaching, website, articles or promotional material, in the UK and abroad.

Please tick one of the boxes below to indicate consent for these images to be used:

   
 
I consent to all images being used anonymously under the Data Protection Act 1998 (please see Terms and Conditions)
   
I consent to all images being used anonymously under the Data Protection Act 1998 (please see Terms and Conditions)
apart from those where my face is shown
   
I do not consent to any images being used