Covid-19 Questionnaire

Ainsty Dental

Please complete the form  below before your upcoming appointment. If attending as a family please submit a separate form for each individual member. If you have attended the practice within the last 2 weeks you do not need to submit an additional form.

Have you been diagnosed with Coronavirus?

Do you have a fever or have you/they felt feverish recently (14-21 days)?

Are you having shortness of breath or other difficulties Breathing?

Do you currently have a cough? or have you had a persistent dry cough in the last 14 days?

Do you have any other flu like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you experienced a loss of taste or smell?

Are you in contact with any confirmed Covid-19 positive patients?

Have you travelled in the past 14 days to any regions affected by Covid-19?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Are you 70 years old or above?

Please also complete the following Medical Questions if it has been more than 3 months since your last visit or you are new to the practice.

Or if you have recently been in then please scroll to the bottom of the form and click submit.

Have you ever suffered from rheumatic fever?

Do you suffer from Asthma, Chronic Bronchitis or any other respiratory disease?

Do you have Diabetes?

Do you have Epilepsy?

Have you ever suffered from Hepatitis, Jaundice, Liver or Kidney Disease?

Do you have high blood pressure or Angina?

Do you have heart disease, or suffered a heart attack or any related complaints?

Do you have a pacemaker?

Do you suffer from Arthritis?

Have you ever had a joint replacement operation?

Have you had steroid therapy in the last 2 years?

Do you suffer from cold sores?

Do you have HIV?

Have you had a recent blood test, if so why?

Has a blood donation ever been refused?

Have you ever undergone hospitalisation that may affect dental care?

Do you have any other serious medical condition?

Are you currently undergoing any medical treatment?

Are you at present taking any medication?

Do you have any allergies?

Are you expecting a baby, if so when is your due date?

Do you smoke, if so how many per day?

How many units of alcohol do you drink per week?
(1 unit = ½ pint of lager, 125ml wine, 25ml spirit)