Health Risk Assessment22

Health Risk Assessment & Medical History

Please complete the following questions for risk assessment and consent prior to attending Singleton Dental. Your answers will be recorded in your dental records held by Singleton Dental, and will be used to help provide you with correct and safe dental treatment.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart trouble or high blood pressure
Diabetes
Asthma
Epilepsy
Allergies to medications or other substances
Dental anxiety
Mental illness
Blood clotting disorder or taking anticoagulant medication
None of the above
 
 
 
 
 
I confirm my consent.