North Shore Dental Patient Questionnaire

Title
First name
Last name
Address
Home phone
Business phone
Mobile phone
Email
Preferred method of contact
(From time to time we may forward information by email. Please let us know if you do not wish to be included in this.)
Date of birth
Occupation
Name of last dentist
Person who referred you, or the source of your learning of us:
If under 20, name & address of Parent/Guardian
Name of medical practitioner
If you are attending school, which school do you attend?
CONFIDENTIAL HEALTH QUESTIONNAIRE
In order to provide the best and safest dental treatment, your dentist needs to know of any medical problems which may affect your treatment. Please see the health information consent section at the end of this document.
1. Are you receiving any medical treatment at the present time?
No
Yes
2. Have you been a patient in hospital during the past 2 years?
No
Yes
3. Tick any of the following which you have had:
Rheumatic fever
Heart trouble
High blood pressure
Asthma
Arthritis
Hepatitis
Bronchitis or chest problems
Epilepsy
Anaemia
Diabetes
Kidney trouble
Gastric problems
Cold sores
Depressive illness
Do you get severe headaches?
If you get severe headaches, how often?
Are you apprehensive of Dental Treatment?
No
Slightly apprehensive
Moderately apprehensive
Extremely apprehensive
4. Are you taking any tablets, capsules, medicines or drugs?
No
Yes
If yes, please list:
5. Have you had any allergies to medicines that you are aware of?
No
Yes
5. If yes, please list
6. Have you had any prosthetic surgery? (eg heart valve or hip replacement)
No
Yes
7. Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
No
Yes
8. Have you ever had contact with the HIV virus or Hepatitis B virus?
No
Yes
9. Have you ever had a reaction to an anaesthetic?
No
Yes
10. Women - are you pregnant now?
No
Yes
If you are pregnant, how many months?
11. Is there any family history of diabetes?
No
Yes
Are there any other aspects concerning your health that you think your dentist should know about?
Comments or additional information
SMILE EVALUATION
If you would please respond to the questions below, it will help us to help you more
1. Do you like the appearance of your teeth and your smile?
Yes
No
2. Are your teeth all in alignment (straight)?
Yes
No
3. Do you have spaces that you don't like?
Yes
No
4. Do you like the colour of your teeth?
Yes
No
5. Do you like the shape of your teeth?
Yes
No
6. Are your teeth chipped, protuding or hidden?
Yes
No
7. Are there old fillings or dental work that you don't like looking at?
Yes
No
8. What would you most like to change or improve in the appearance of your teeth?
Thank you for choosing us as your dental health care provider. To maintain the practice operation and prevent potential misunderstanding, we ask patients to adhere to the financial arran gements regarding their treatment. Payment is required at the time services are rendered. We can offer extended payment for some treatments, please ask our staff for details prior to commencing treatment. Overdue accounts will incur fees. Fees also apply for broken appointments without proper notification.
I consent to North Shore Dental collecting and keeping information about my health for the purpose of making sure that I receive appropriate care and treatment, and for associated administrative tasks. I understand my relevant health information will be stored by North Shore Dental, and that I am entitled to request access to and correction of my health information. I agree to provide this information voluntarily.
I understand and agree with the above financial and health information policies
At North Shore Dental we want to make your experience as relaxed and comfortable as possible as we all know that coming to the dentist isn’t your favourite place to be.
To ensure your visits with us are the most pleasant please tick any of the following that may apply to you:
I get nervous with the smell of the dental practice
My time is in demand - please don't keep me waiting
Finances are a concern for me, please tell me about my options
I've had a bad dental experience in the past
I get nervous around needles
I don't like the sound of the drill
I want to know every aspect of my treatment before you do it
I don't want to know about the details, just do it
I want to feel in control of my treatment appointment
I get uncomfortable in the dental chair
I have a strong gag reflex
I find it hard to keep my mouth open for so long
I get really cold in the dental chair
Or tell us something else about how you feel:
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OPEN HOURS
Monday 8.00am - 6.30pm
Tuesday 8.00am - 6.00pm
Wednesday 8.00am - 7.00pm
Thursday 8.00am - 6.00pm
Friday 8.00am - 5.00pm
Saturday 8.30am - 3.00pm

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CONTACT US
Phone:  (09) 478 7442
Fax: (09) 478 7441
info@northshoredental.co.nz

Address
Corner of Anzac & Beach Roads
Browns Bay
Auckland
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