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  Group-CS: Ortho
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  CS: Maryland
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Patient Medical Questionnaire

Medical History Questionnaire

Dear Ladies and Gentlemen,

To help us provide safe, complication-free treatment and to comply with official regulations, we kindly ask you to share some important information with us. All details you provide will be kept strictly confidential in line with government data protection policies. If you experience any difficulties completing the form, please don’t hesitate to ask — we’ll be happy to assist you in person.

Thank you!

Personal Data

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 Town/City Post Code Country

Medical History

Have you recently been hospitalised (in the last 12 months)?(Required)

Yes

No

If yes, please share what for and how you we're treated please:

Do you have any underlying medical conditions we should be aware of?(Required)

Yes

No

If yes, please share what the medical conditions are please:

Name of your general practitioner (GP)

Are you taking any medication regularly at the moment?(Required)

Yes

No

If yes, what? Please list any medication below:

Please tick if you're taking any of the following medication:

Antidepressants (important if surgery is planned!)

Medication for Anticoagulation (e.g. Marcumar, Aspirin)

Painkillers

Bisphosphonates due to osteoporosis in the last years

Do you bleed longer than normal after injuries?(Required)

Yes

No

Have you ever had...

Any unusual reactions to injections or medication?(Required)

Yes

No

(e.g. iodine, penicillin etc.)

Asthma, hay fever or other allergies?(Required)

Yes

No

Heart or circulation diseases?(Required)

Yes

No

(e.g. Hyper-, Hypotonic, Endocarditic problems, replacement of the heart valves, infections)

Rheumatic diseases or pain in the joints?(Required)

Yes

No

Liver diseases?(Required)

Yes

No

(e.g. jaundice)

Diabetes?(Required)

Yes

No

Respiratory diseases?(Required)

Yes

No

Kidney diseases?(Required)

Yes

No

Infectious diseases?(Required)

Yes

No

(e.g. Tuberculosis, AIDS, HIV, Hepatitis, Gonorrhoea)

Do you suffer from insomnia or snoring?(Required)

Yes

No

Do you have problems with the thyroid?(Required)

Yes

No

Epileptic seizures?(Required)

Yes

No

Do you smoke?(Required)

Yes

No

If yes, how many per day?

Do you drink alcohol?(Required)

Yes

No

If yes, how many units a week?

Small glass of red/white/rosé wine (125ml, ABV 12%) - 1.5 units. Bottle of lager/beer/cider (330ml, ABV 5%) - 1.7 units. Can of lager/beer/cider (440ml, ABV 5.5%) - 2.4 units.

For female patients: Are you pregnant?(Required)

Yes

No

If yes, by how many weeks?

Do you have an artificial hip?(Required)

Yes

No

Dental Health History

Do you currently have any issues with your teeth or oral health that immediately require the attention of a dentist?(Required)

Yes

No

If yes, where?

Do you have problems with your gums?(Required)

Yes

No

If yes, where?

Is your chewing ability reduced?(Required)

Yes

No

Are you happy/comfortable with the look of your teeth?(Required)

Yes

No

If no, what specifically do you not like/not comfortable with?

Do you suffer from any symptoms of TMJ? Or have you been diagnosed with TMJ?(Required)

Yes

No

TMJ problems can cause pain or tenderness around the jaw and ears, clicking or popping noises when opening and closing the mouth, and difficulty fully opening the jaw or episodes of locking. People often experience headaches, neck or shoulder tension, and may notice their bite feels uneven or has changed. In many cases, teeth grinding or clenching also leads to visible wear on the teeth.

Do you have chronic head-, neck- or shoulder problems?(Required)

Yes

No

The reason for your dental visit?

Are you interested in any of the below treatments?

Dental Hygiene

Gum Disease

Root Canal Treatment

Full mouth reconstruction

Therapy of the TMJ

Implants

Cosmetic Dentistry (e.g. veneers, teeth whitening)

Halitosis (Bad breath) etc.

Specialist care for nervous patients

Other

If you have selected "Other" please tell us what you are interested in speaking to our dental team about:

How did you find us

I found Wimpole Street Dental Clinic due to...(Required)

Word of mouth

Google

Bing

Facebook

YouTube

Instagram

TopDoctors

Newspaper/Offline Media

Walked past building

Other

Important information

You must not drive when you had local injections and you are still numb.
As we reserve these appointment times especially for you, we kindly ask that you provide at least 48 working hours’ notice if you need to cancel or reschedule. Cancellations made with less than 48 working hours’ notice will incur a fee.

The SMS reminder is a service from our clinic. In case you want to cancel your appointment, please call us.

If your personal data and your medical status change we would like to ask you to inform us immediately. I assure that the given information is correct.

I agree that my personal data, e.g. x-rays and photographs and their respective copies can be used for scientific purposes, and can be forwarded to medical colleagues, insurances and debt collections services.

To keep your teeth healthy in the long run, we would like to inform you about your regular check-ups and dental hygiene.(Required)

How would you like to be reminded?

SMS

Email

Telephone

With your signature you verify that the data you have given are true to your best knowledge and that you are happy with the statement above.(Required)

Please write your name in full as your signature.

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Contact Details

38 Queen Anne Street
Marylebone
London
W1G 8HZ

T 020 3745 7455
E reception@wsdental.clinic

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