Meavy Way Dental Practice – Dental Focus Secure Forms

If you or anyone you live with has any symptoms of Coronavirus please do not come to the practice and contact the reception team to rearrange your appointment.
- Patient Details
- Patient Name*
  Title First Name Surname
- Patient Address*
  Address Line 1 Address Line 2 City Postcode
- Patient Date of Birth*
  
  Day
  Month
  Year
- Email Address
- Home Phone Number
- Mobile Phone Number
- Your Occupation
- Ethnicity
- Your GP's Details
- Doctor's Name*
- GP Surgery Name*
- Practice Address
  Address Line 1 Address Line 2 City Postcode
- COVID 19 Specific Medical History
- Hidden
  Have you been diagnosed with coronavirus?*
  - Yes
  - No
- Hidden
  Have you had COVID-19 within the last 10 days?*
  - Yes
  - No
- Hidden
  Have you been in contact with someone with confirmed/suspected coronavirus?*
  - Yes
  - No
- Hidden
  Are you waiting for a COVID-19 PCR result?*
  - Yes
  - No
- Hidden
  Are you or your household self-isolating?*
  - Yes
  - No
- Hidden
  Have you travelled internationally in the last 10 days to a country outside of the UK?*
  - Yes
  - No
- Hidden
  Have had any symptoms of the coronavirus in the last 14 days?*
  - Yes
  - No
- Hidden
  Have you been identified by your health protection team as someone who should be in respiratory isolation?*
  - Yes
  - No
- Hidden
  Do you have any of the following symptoms that could be COVID-19 or influenza*
  - high temperature or fever?
  - new, continuous / dry cough?
  - a loss or alteration to taste or smell?
  - muscle aches
  - sore throat
  - headache
  - Yes
  - No
- Hidden
  Are you considered a ‘shielded/ vulnerable’ patient due to underlying health conditions?*
  - Yes
  - No
- Hidden
  Do you have any new or worsening respiratory symptoms not already mentioned?*
  - Yes
  - No
- Hidden
  Do you have any mobility issues?*
  - Yes
  - No
- Hidden
  Have you been diagnosed with a confirmed respiratory infection such as influenza?*
  - Yes
  - No
- Hidden
  As you've answered yes to a screening question, please give further details about your answer
- You are a category 1 patient
- You are a category 2 patient
- You are a category 3 patient
- Carer/guardian risk assessment:
- Hidden
  Will you need a chaperone at your appointment?*
  - Yes
  - No
- Hidden
  If yes, in what capacity? Please give the name and phone number of the chaperone.*
- Hidden
  It may be best if they were to wait for you outside to reduce the transmission risk of COVID-19. Would this be acceptable to you?*
  - Yes
  - No
- Your Medical History Details
  Do you have any of the following.
- Are you currently taking any prescribed or non prescribed medication?*
  - Yes
  - No
- Medication List*
  Medication Dose When Taken (How Often) For Which Condition
- Rheumatic Fever
  - Yes
  - No
- High Blood Pressure
  - Yes
  - No
- Stroke
  - Yes
  - No
- Epilepsy
  - Yes
  - No
- Fainting Attacks
  - Yes
  - No
- Blackouts
  - Yes
  - No
- Asthma
  - Yes
  - No
- Hayfever
  - Yes
  - No
- Eczema
  - Yes
  - No
- Steroid Treatments
  - Yes
  - No
- Heart Complaint
  - Yes
  - No
- Please enter details
- Are you Diabetic?
  - Yes
  - No
- Please enter details
- Excessive bleeding (blood thinning meds)
  - Yes
  - No
- Please enter details
- Arthritis/Osteoporosis
  - Yes
  - No
- Please enter details
- Operation in last 2 years
  - Yes
  - No
- Please enter details
- Joint replacement
  - Yes
  - No
- Please enter details
- Blood-borne viruses (HIV, Hepatitis B/C)
  - Yes
  - No
- Please enter details
- Any other medical condition
  - Yes
  - No
- Please enter details
- Do you or are you:
- Pregnant
  - Yes
  - No
- If yes, please enter details (eg due date)
- Carry a warning card
  - Yes
  - No
- If yes, please enter details
- Allergic to anything (penicillin/latex etc)
  - Yes
  - No
- If yes, please enter details
- A smoker (including tobacco/vape)
  - Yes
  - No
- If yes, please enter details (amount per day)
- Drink alcohol
  - Yes
  - No
- If yes, please enter details (units per week)
- Any Other Information
- If there is any other information which has not been asked on this form that you feel the dentist should know about?
- Consent and Signature
- I confirm that the above information is correct to the best of my knowledge.*
  - I CONFIRM
- Hidden
  I have been advised that by attending the practice I may be putting myself and family members at risk from coronavirus*
  - I CONFIRM
- I give my consent for the above information to be stored in the interests of maintaining my oral health and for the practice to contact me about my treatment*
  - I CONFIRM
- My preferred method of contact
  - Email
  - Phone
  - Text
- Hidden
  Do you consent to NHSBSA to use this method of contact to survey your NHS experience?
  - Yes
- Signature
Name
This field is for validation purposes and should be left unchanged.

Medication	Dose	When Taken (How Often)	For Which Condition

Meavy Way Medical History Pre-Appointment Form

Patient Details

Your GP's Details

COVID 19 Specific Medical History

You are a category 1 patient

You are a category 2 patient

You are a category 3 patient

Carer/guardian risk assessment:

Your Medical History Details

Do you or are you:

Any Other Information

Consent and Signature

You are now in a secure area