Patient Registration and Health Questionnaire Personal DetailsName* First Last Date of Birth* DD slash MM slash YYYY Male/Female/Non-Bianary* Male Female Non-Bianary Address* Street Address Address Line 2 City Email* LandlineMobile*Next of Kin First Last Contact number of next of kinHeight (in cms or feet. Leave the field empty if not sure)Weight (in kgs. Leave the field empty if not sure)Are you on benefit? Do you want a WINZ quote?*Who referred you here?Name of the last dentist/dental centre*Name of your GP / ClinicIs your treatment covered under ACC?* Yes No Don't know Please answer all questions by circling YES or NO and fill in the blank spaces where indicated.Are you currently under the care of a specialist/doctor?* Yes No If YES, what condition(s) is/are being treated?*Have you had a serious illness or operation? Yes No If YES, what was the illness or operation?Have you been hospitalised in last 5 years?* Yes No If YES, what was the problem?*Do you have had any of the following?Rheumatic fever or Rheumatic Heart Disease* Yes No Heart abnormalities present since birth* Yes No Cardiovascular Disease(Heart Trouble, heart attack, stroke, high blood pressure, heart murmur)* Yes No Asthma* Yes No Fainting Spells or Seizures* Yes No Diabetes* Yes No Hepatitis, Liver Disease* Yes No Stomach Ulcers* Yes No Kidney Trouble* Yes No Arthritis* Yes No Psychiatric treatment* Yes No Epilepsy* Yes No Other conditions or medications not mentioned above, please list.Have you had any serious bleeding trouble?* Yes No Are you taking any blood thinners like Aspirin(Cartia), or Warfarin.* Yes No Have you had any serious trouble associated with previous dental work?* Yes No Have you ever had joint replacement surgery?* Yes No Do you smoke?* Yes No Are you pregnant?* Yes No AllergiesLocal Anesthetics* Yes No Not sure Penicillin and/or other Antibiotics* Yes No Not sure Iodine* Yes No Not sure Any other allergies, please list.Consent* I UNDERSTAND THAT MY ANSWERS TO THE QESTIONS ARE FOR YOUR RECORDS ONLY AND ARE CONFIDENTIAL.I accept that the information provided in this form is true and I will take full responsibility of the wrong information.
