Welcome to Anokhi Dental

So that we may provide you with the best possible care, please take the time to complete this form.

All information provided is completely confidential.

New Patient Form

Name *
Name
DD/MM/YYYY
Address *
Address
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In case of emergency
In case of emergency
MEDICAL HISTORY
Have you been under the care of a medical doctor or practitioner during the past two years? *
Have you been a patient in hospital in the past five years? *
Are you taking any medications or drugs now? *
Have you ever taken any bisphosphonate medications? *
Are you taking vitamins or supplements now? *
Are you allergic to any medications, including penicillin? *
Please indicate which of the following you have (or have had) and provide details:
Heart Disease (angina, attack, dysrhythmia) *
Congenital heart disease (heart murmur, Prolapsed mitral valve) *
Rheumatic Fever/Endocarditis *
Heart Surgery *
Artificial heart valve or pacemaker *
Stroke *
High/Low Blood Pressure *
Bleeding abnormalities (warfarin therapy, Haemophilia) *
Respiratory Disease (asthma, bronchitis, Emphysema) *
Diabetes *
Thyroid Disease *
Kidney/Urogenital Disease *
Liver Disease (jaundice, cirrhosis) *
Digestive Disorders (reflux, leaky gut, Candida) *
Multiple Sclerosis *
Osteoporosis *
Arthritis/Artificial Joints (hip, knee etc) *
Malignancy *
Chemotherapy *
Radiotherapy *
Surgery *
Allergies (hay fever, latex) *
Neurological Disorders (anxiety, depression, Epilepsy, dementia) *
Chronic Fatigue Syndrome *
HIV/AIDS *
Hepatitis *
Tuberculosis *
Do you smoke or consume alcohol? *
General Fatigue *
Daytime Sleepiness *
Insomnia *
Irritability *
Unexpected Weight Gain *
Have you ever had a sleep study? *
Have you ever seen an Ear Nose Throat Specialist (ENT)? *
Ladies are you:
Taking Birth Control *
Planning pregnancy *
Breastfeeding *
Undergoing IVF *
Dental History
Do you have any dental problems now? *
Do your gums bleed or hurt? *
Do you experience bad breath or a bad taste in your mouth? *
Have you noticed any loose teeth or change in your bite? *
Does food get caught between your teeth? *
Do you experience mouth ulcers, cold sores or any other lesions? *
Have you ever experienced dental infections? *
Have you had dental decay or fillings? *
Have you had any crowns or bridges placed in your mouth? *
Have you ever had root canal treatment? *
Do you have dental implants? *
Are any of your teeth sensitive to:
Hot or Cold *
Sweet *
Biting or Chewing *
Do you experience difficulty chewing? *
Are you missing teeth? *
Do you wear dentures? *
Do you ever clench or grind your teeth? *
Have you ever had:
Your teeth ground or bite adjusted? *
A bite plate or mouthguard? *
Do you experience:
Clicking or popping of the jaw? *
Headaches, neck or shoulder tension? *
Tired jaws, especially in the morning? *
Are you sensitive to anaesthetics and /or dental materials? *
Are you dissatisfied with the appearance of your teeth? *
Do you feel nervous about having dental treatment? *
Have you ever had an upsetting dental experience? *
*