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Social & Dental History

Form 2

PLEASE WRITE CLEARLY

For Office Use Only DD MM YY
CHI Number 

When did you last see a dentist? (If you cannot remember, please tick the most likely option)

Have you received any dental treatment under local anaesthetic (an injection into the gum)? If yes, please note whether it caused you any problems

Q1 Choice *

Do you currently have any problems or concerns with your teeth, gums or mouth?

Q2 Choice *

Do you play a sport where you have the potential to damage your teeth?

Q3 Choice *

Do you wear a denture, brace or retainer?

Q4 Choice *

As far as you are aware, do you grind or clench your teeth?

Q5 Choice *

Do you have a family history of gum disease (periodontitis)?

Q6 Choice *

Are you anxious or nervous about attending the dentist?

Q7 Choice *

Which of the following do you use each day? (Please tick appropriate boxes)

Checkboxes *

Which of the following do you have each day? (Please tick appropriate boxes)

Checkboxes *

Have you ever used chewing tobacco, paan, gutkha, supari or beetle quid? (Please tick the appropriate box)

Q8 Choice *

Smoking Status (Please tick appropriate box)

Smoking Status *

Alcohol Consumption

1 unit of alcohol = 

  • half a standard 175ml glass of wine (12.5% ABV)
  • half a pint of normal strength beer, lager or cider (4% ABV)
  • one 25 ml measure of spirits (40% ABV)

On average, how many units do you drink in a week?

What is the largest number of units you drank in a single day in the last week?

All Patients

In your view, how likely is it that the health of your teeth will affect your overall wellbeing? (Please select the appropriate box)

Additional Information

After you have completed this form please return it to a member of the Dental Team.