orchard dental practice | dental health in maidenhead | from hygene to cosmetic dentistry & oral surgery

To join the practice as a patient you can pop into our surgery and pick up a medical questionnaire form, or alternatively use our online form below and send it to us from this site!

Before we are able to examine you or provide any dental treatment, it would be appreciated if you could complete the following questionnaire. It is important for us to know of any medication you are taking, and any illnesses that you have or have had in case they could affect your dental health and proposed treatment.

The information that you give here will be used solely by the Orchard Dental Practice and will be treated with the utmost confidence. At no time will we pass any of this information on to third parties for marketing, research or any other activity.

Personal Details

Surname			Title
Forenames
Date of birth			Occupation
Private Address
Postcode			Phone
Mobile Phone			E-mail


Business Address
Postcode			Phone


Medical Practitioner			Surgery No
Were you recommended?			If so by whom?

Medical & Dental History

Are you currently...
...attending or receiving treatment from your doctor, hospital, clinic or specialist?
...taking or using any tablets, pills, medicines or drugs (including the contraceptive pill)? If yes please state below.
enter medications here

Do you...
...take steroids or have you taken steroids in the last two years?
...have any allergies to drugs (especially penicillin), medicines or antiseptics? If yes please state below.
enter drug allergies here

Have you ever...
...been told you have a heart murmur, heart problem, high blood pressure, angina or had a heart attack?
...had Rheumatic Fever or Chorea?
...had Jaundice, liver disease, kidney disease or hepatitis?
...had Diabetes, Glaucoma or Epilepsy?
...had a joint replacement?
...had a pacemaker fitted?
...had any other serious illness?

Women...
...are you pregnant?
...are you breast feeding?

Do you ever suffer pain when...
...eating cold, hot or sweet foods?
...chewing?

Do you have any other dental problems?
Please state below.
enter other dental problems here

Approximately when was your last visit to a dentist? (in years then months e.g. 3, 5)

Personal Details

Surname

Title

Forenames

Date of birth

Occupation

Private Address

Postcode

Phone

Mobile Phone

E-mail

Business Address

Postcode

Phone

Medical Practitioner

Surgery No

Were you recommended?

If so by whom?

Medical & Dental History

Are you currently...

...attending or receiving treatment from your doctor, hospital, clinic or specialist?

...taking or using any tablets, pills, medicines or drugs (including the contraceptive pill)? If yes please state below.

Do you...

...take steroids or have you taken steroids in the last two years?

...have any allergies to drugs (especially penicillin), medicines or antiseptics? If yes please state below.

enter drug allergies here

Have you ever...

...been told you have a heart murmur, heart problem, high blood pressure, angina or had a heart attack?

...had Rheumatic Fever or Chorea?

...had Jaundice, liver disease, kidney disease or hepatitis?

...had Diabetes, Glaucoma or Epilepsy?

...had a joint replacement?

...had a pacemaker fitted?

...had any other serious illness?

Women...

...are you pregnant?

...are you breast feeding?

Do you ever suffer pain when...

...eating cold, hot or sweet foods?

...chewing?

Do you have any other dental problems?

Please state below.

Approximately when was your last visit to a dentist? (in years then months e.g. 3, 5)