Covid-19 Questionnaire

Ainsty Dental

    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)