We take your health very seriously

It is vital for all patients attending The Gentle Dental to complete our secure and confidential Medical and Dental Questionnaire (MDQ) before their first appointment. It is designed to give us all of the information we require to provide you with the best care possible. This form will take around 10-15 minutes to complete and has been developed over many years of experience. Please do take the time to do it completely, every detail is important. You can start the form and return to it later to complete.

If you are a new patient to The Gentle Dental, please ensure that we receive your completed form at least 24 hours before your consultation so that we may prepare properly for your first visit.

If you are already a patient at The Gentle Dental, we will also update this form each time you attend the practice to ensure that we always have the up-to-date status of your current medical and dental health. Your data will be securely stored and this form will be editable in future without needing to be completed in full again.

Medical and Dental Questionnaire

Please complete the form

Contact Information and Personal Details 

Name required , First and Last are required.
Address required ,
Please provide your GP practice details required ,
How did you hear about us? required ,

Medical History

Are you pregnant, possibly pregnant, or breastfeeding? required ,
Are you currently receiving treatment from a doctor, hospital or clinic? required ,
Do you suffer from allergies, including hay fever, eczema, any medicines (e.g. penicillin), substances (e.g. latex/rubber) or foods? Or have you got a history of adverse effects to dental materials? required ,
Are you carrying a medical warning card? required ,
Do you suffer from bronchits, asthma or other chest conditons? required ,
Do you suffer from fainting attacks, panic attacks, giddiness, blackouts or epilepsy? required ,
Do you suffer from heart problems? required ,
Do you suffer from high blood pressure  required ,
Do you suffer from any blood borne diseases (including HIV and hepatitis)? required ,
Are you diabetic? required ,
Do you suffer from arthritis? required ,
Do you suffer from bruising or persistent bleeding following injury, tooth extracton or surgery? required ,
Do you suffer from Angina or have a pacemaker? required ,
Have you ever had liver disease (e.g. Jaundice, hepatitis) or kidney disease? required ,
Have you ever had Blood Refused by the Blood Transfusion Service? required ,
Have you ever had a bad reaction to general or local anaethetic? required ,
Have you ever had heart surgery or brain surgery? required ,
Have you ever had radiaton therapy to head or neck required ,
Do you have a history of mental health problems? required ,
Do you now, or have you ever, suffered from any eating disorders? required ,
Do you suffer from Gastro-Oesophageal or Acid Refux? required ,
Do you take Bisphosphonate medicaton for your bones? Have you in the past? Are you likely to in the future (for osteoporosis / steroid use / bone cancer / Padget’s disease) required ,

Social History

Do You Smoke? required ,
Do you drink alcohol? required ,

Due to the recent COVID-19 Pandemic we would like to ask some further questions 

Have you been in communication with someone who may have COVID-19 (coronavirus) infection or had any of the following recently? required ,
Have you been diagnosed with having COVID-19? required ,
If Yes to the above, Have you been tested for immunity? required ,

Is there anything else you wish to tell us?

Wishes, expectations, constraints and considerations.

Sometimes patients do not feel that they have been able to ask all of the questions they wanted to ask or convey all of the information they wished to convey when they attend for their consultation.

Please take the time to complete the following section as thoroughly as possible in your own time in advance so that we can be well prepared for you when we meet.

Please include as much detail as possible, whether it is about your appearance, your comfort, your feelings, other people’s impression of you or indeed anything that matters.

Has the potential financial investment involved ever influenced you seeking ideal treatment? required ,
If so, would you be interested in taking advantage of a payment plan or staging treatment over a period of time? required ,

Please read carefully and indicate consent as appropriate

Please note that all treatment carried out at The Gentle Dental is photographically and occasionally video documented as part of your clinical record. As well as being a necessary and indispensible part of your clinical record, these images may be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK and abroad. We are bound by current General Data Protection Regulation (GDPR) 2018. (Please see The Gentle Dental current Terms and Conditions.) Please indicate how you would like these images to be used:

Consent for use of clinical images and video required ,
Consent for use of all clinical data held by The Gentle Dental: I consent to my clinical images and data being shared within The Gentle Dental practice for the purposes of clinical care and with dental or medical colleagues outside the practice such as anaesthetists, dental or medical colleagues, scanning centres, dental laboratories and other third parties directly involved with or advising on my clinical care at The Gentle Dental. Please note that answering “No” will mean that we are unable to accept you as a patient at The Gentle Dental  required ,
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