Social & Dental History

Surname*

Please enter your name

Forename*

Please enter your first or given name

When did you last see a dentist?*

Do you play a sport where you have the potential to damage your teeth?*

YES NO UNSURE Please answer this question

Do you wear a denture, brace or retainer?*

YES NO UNSURE Please answer this question

As far as you are aware do you grind or clench your teeth?*

YES NO UNSURE Please answer this question

Do you have a family history of gum disease (periodontitis)?*

YES NO UNSURE Please answer this question

Are you anxious or nervous about attending the dentist?*

YES NO UNSURE Please answer this question

Which of the following do you use each day? (Please tick appropriate boxes)*

Which of the following do you have each day? (Please tick appropriate boxes)*

Sugary carbonated (fizzy) drinks
Around 5 portions of fruit and vegetables
Diet carbonated (fizzy) drinks

Sugary treats (sweets and biscuits) between meals
Sugar in hot drinks

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Have you ever used chewing tobacco, paan, gutkha supari or beetle quid? (Please tick appropriate box)*

YES NO UNSURE Please answer this question

Smoking Status

Smoking Status (Please tick appropriate box)*

I have never smoked I am an ex-smoker I am a smoker Please answer this question

Number of cigarettes etc smoked per day

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Number of years an ex-smoker

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Alcohol Consumption

half a standard 175ml glass of wine (12.5% abv)

1 unit of alcohol = half a pint of normal strength beer, lager or cider (4% abv) one 25 ml measure of spirits (40% abv)

On average how many units do you drink in a week?

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What is the largest number of units you drank in a single day in the last week?

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All Patients

In your view, how likely is it that the health of your teeth will affect your overall wellbeing? (Please tick appropriate box)*

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Additional info

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Name of Patient/ Parent or Carer*

Please type your name

Signature of Patient, Parent or Carer*

Sign Above

Please sign your name

Date*

Please enter the date

Submit

Smoking Status

Alcohol Consumption

All Patients

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