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DrMrMrsMsMasterMiss
Question
Yes/No
Do you have missing teeth?
YesNo
Do you have broken teeth?
Do you have silver fillings?
Do you have plastic/white fillings?
Are you happy with your smile?
Are you happy with the shade of your teeth?
Condition
Asthma
Abnormal Bleeding
Anaemia
Arthritis
Artificial Valves Prostheses
Cardiac Arrest
Diabetes
Hepatitis (A / B / C / D)
High Blood Pressure
HIV/AIDS Positive
Osteoporosis
Pacemaker/Cardiac Surgery
Pregnant
Previous Anaesthetic Problems
Rheumatic Fever
Thyroid Disorder
Do you have any allergies? *
PenicillinLatexOther
Do you drink alcohol? [text* drink*]
Medications
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