Covid-19 Questionnaire Ainsty Dental Have you ever suffered from rheumatic fever? YesNo Do you suffer from Asthma, Chronic Bronchitis or any other respiratory disease? YesNo Do you have Diabetes? YesNo Do you have Epilepsy? YesNo Have you ever suffered from Hepatitis, Jaundice, Liver or Kidney Disease? YesNo Do you have high blood pressure or Angina? YesNo Do you have heart disease, or suffered a heart attack or any related complaints? YesNo Do you have a pacemaker? YesNo Do you suffer from Arthritis? YesNo Have you ever had a joint replacement operation? YesNo Have you had steroid therapy in the last 2 years? YesNo Do you suffer from cold sores? YesNo Do you have HIV? YesNo Have you had a recent blood test, if so why? YesNo Has a blood donation ever been refused? YesNo Have you ever undergone hospitalisation that may affect dental care? YesNo Do you have any other serious medical condition? YesNo Are you currently undergoing any medical treatment? YesNo Are you at present taking any medication? YesNo Do you have any allergies? YesNo Are you expecting a baby, if so when is your due date? YesNo Do you smoke, if so how many per day? YesNo How many units of alcohol do you drink per week? (1 unit = ½ pint of lager, 125ml wine, 25ml spirit)
